SAUNDERS' 
MEDICAL  HAND-ATLASES. 


•efo* 


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ATLAS  AND  EPITOME 


iS! 


OF 


DISEASES   OF  CHILDREN^ 


>2    " 

"•    DR.   R:  HECKER  and  DR.  J.  TRUMPP 

of  the  University  of  Munich 


Autho)-ized  Translation  from  the   German 


EDITED  BY 

ISAAC  A.  ABT,  M.D. 

Assistant  Professor  of  the  Diseases  of  Children  in  Rush  Medical  College, 
in  affiliation  with  the  University  of  Chicago 


With  48  Colored  Plates  And  147  BUck  and  White  Illustrations 


PHILADELPHIA    AND   LONDON 

W.  B.  SAUNDERS  COMPANY 

1907 


K07 


Copyright,  1907, 
By  W.  B.  SAUNDERS  COMPANY 


ELEOTROTVPCO  BV  PRESS   OF 

WeSTCOTT  *  THOMSON,  PHILADA.  ^    ^^  SAUNDERS  COMPP.W 


EDITOR'S    PREFACE 


The  text  of  the  present  volume  forms  a  manual  of 
Pediatrics  in  small  compass.  The  plates,  as  will  be  seen 
on  examination,  are  very  life-like  and,  as  in  the  other 
volumes  of  "  Saunders'  Hand- Atlases,"  accurately  por- 
tray the  conditions  they  are  intended  to  represent. 

The  additions  by  the  Editor  will  be  found  enclosed  in 
brackets.  Considerable  changes  have  been  made  in  the 
sections  on  Therapeutics,  and  these  have  been  revised  in 
accordance  with  the  practise  in  this  country.  This  was 
called  for,  especially  since  many  of  the  climatic  measures, 
health  foods,  and  apparatus  are  not  to  be  obtained  in  the 
United  States. 

3 


PREFACE 


Pediatrics  is,  unfortunately,  still  the  stepchild  of  our 
universities.  It  is  true  that,  owing  to  its  eminently  prac- 
tical importance,  it  is  included  as  a  secondary  subject  in 
the  general  examination  for  the  degree  in  medicine,  but 
many  universities,  nevertheless,  are  still  without  pediatric 
clinics  and  separate  chairs  for  diseases  of  children. 
Under  these  circumstances  it  is  no  wonder  that  tlie 
pediatric  education  of  many  students  and  young  physi- 
cians, who  have  been  obliged  to  get  their  knowledge  of 
the  subject  from  text-books,  leaves  much  to  be  desired. 
The  best  t€xt-book  cannot  take  the  place  of  clinical 
observation,  but  this  deficiency  can,  to  a  great  extent  at 
least,  be  supplied  by  pictorial  illustrations,  provided  they 
are  given  in  sufficient  numbers  and  arranged  in  series  in 
a  manner  adapted  to  the  use  of  students. 

Tlie  current  text-books  on  pediatrics  do  not  meet  this 
requirement,  and  the  authors  have,  therefore,  decided  to 
bring  out  this  "Atlas  of  Diseases  of  Children"  in  the 
hope  that  it  will  enable  students  and  young  practising 
physicians  who  have  not  had  the  advantage  of  clinical 
instruction  to  gain  a  better  understanding  of  systematic 
text-books,  and  that  the  epitome  which  the  Atlas  contains 
may  serve  as  a  convenient  summary  of  the  subject.  We 
also  hope  that  teachers  may  occasionally  find  the  book 
useful  in  their  class  work. 

5 


6  PREFACE 

In  the  preparation  of  the  ilhistrations  we  have  had  the 
benefit  of  the  kindest  co-operation  from  various  quarters. 
Professors  Escherich  and  Pfaundler  have  kindlv  aHowed 
us  to  reproduce  a  number  of  splendid  illustrations  from ' 
the  collection  of  the  Pediatric  Clinic  in  Vienna  and  Graz. 
Professors  Heubner  and  Stoltzner  furnished  us  some  valu- 
able microscopic  preparations ;  and,  last  but  not  least, 
the  directors  of  the  Miinchener  Institut,  Geheimrat  von 
Panke  (Kinderklinic),  Obermedizininalrat  von  Bollinger 
(Pathologisches  Institut),  and  Professor  Ruckert  (Anat- 
omy), very  kindly  allowed  us  free  access  to  their  Insti- 
tutions. To  all  these  gentlemen,  as  well  as  to  Prosector 
Dr.  Hahn,  Professor  Diirck,  Dr.  Eggel,  and  Dr.  O.  Seitz, 
who  were  kind  enough  to  assist  us  in  the  preparation  of 
specimens,  we  take  this  opportunity  of  expressing  our 
warmest  thanks. 

The  colored  plates  were  furnished  by  the  artists 
Messrs.  Tersch,  Liner,  and  Dirr,  while  the  task  of  pre- 
paring the  engravings  was  undertaken  by  Messrs.  Tersch 
and  Biehl  (Atelier  Elisabeth). 

Mr.  Lehmann,  the  ])ublisher,  has  spared  neither  pains 
nor  expense  in  perfecting  the  external  garb  of  this  work, 
and  we  must  not  neglect  to  express  our  grateful  acknowl- 
edgment of  his  invariable  willingness  to  carry  out  our 
wishes. 

The  Authors. 


LIST  OF  LITHOGRAPHIC  PLATES 


Plate    1. — The  Skulls  of  a  Newborn  Infant,  of  a  Six-year-old  Child, 

of  an  Adult  Man,  and  of  an  Old  Man. 
Platk    2. — Skulls  of  a  Newborn  Infant,  of  a  Six-year-old  Child,  and 

of  a  Man. 
Plate    3. — Fig.  1.— The  Upper  and  Lower  Jaws  of  a  Child  during  the 
Second  Dentition. 

Fig.  2.— Complete  Set  of  ISIilk  Teeth. 
Plate    4. — Congenital  Umbilical  Hernia. 
Plate    5. — Ophthalmoblennorrhea  of  the  Newborn. 
Plate    6. — Fig.  1. — Bony  Development. 

Fig.  2. — Normal  Border  between  Bone  and  Cartilage. 
Plate    7.— Richitis  at  the  Junction  of  the  Bony  with  the  Cartilag- 
inous Portion  of  a  Rib. 
Plate    H. — Fig.  1. — Fetal  Chondnxlystrophia. 

Fig.  2. — Rachitis  of  a  Flat  Cranial  Bone.     Craniotabes. 
Plate    9. — Barlow's  Disease. 
Plate  10. — Purpura  Hemorrhagica. 
Plate  11. — Papular  Rash  of  the  Natesand  Labia  Majora  in  Hereditary 

Syphilis. 
Plate  12. — Fig.  1. — Diphtlieria  of  the  Uvula. 

Fig.  2. — Syphilitic  Infiltration  of  the  Liver. 
Plate  13. — Sypliilitic  Changes  in  the  Kidneys. 
Plate  14. — Fig.  1. — Congenital  Sypliilis  of  the  Intestines. 

Fig.  2. — Sy))hilitic  Osteochondritis. 
Plate  15. — Congenital  Tuberculosis. 
Plate  Ifi.— Scrofula. 

Plate  17. — Acute  Disseminated  Tuberculosis  of  the  Lungs. 
Plate  18. — Fig.  1. — Chronic  Tuberculous  Peritonitis. 

Fig.  2. — Umbilical  Fimgus. 
Plate  19. — Acute  Tuberculous  Basilar  Meningitis. 
Plate  20. — Tuberculosis  of  the  Knee-joint. 

7 


8  LIST  OF  LITHOGRAPHIC  PLATES 

Plate  21. — Early  Symptoms  of  Measles. 

Plate  22. — The  Eruption  of  Measles  Two  D-ays  after  its  First  Appear- 
ance. 
Plate  23. — The  Eruption  of  Kubella  One-half  Day  after  its  Appear- 
ance. 
Plate  24.— The  Exanthem  of  Scarlet  Fever  (Third  Day). 
Plate  25. — Fig.  1. — Scarlatinal  Angina  (Third  Day). 

Fig.  2. — Lacunar  Angina. 
Plate  26. — Normally  Developed  Vaccine  Pustules  on  the  Eighth  D-ay 

after  Vaccination. 
Plate  27. — Tlie  Eruption  of  Varicella  on  the  Fourth  Day. 
Plate  28. — Fig.  1. — Diphtheria  of  the  Lips  following  Mea.sles. 

Fig.  2. — Diphtheria  of  the  Pharynx. 
Plate  29. — Diphtheria  Gravis  (Gangrenous,  Septic  Diphtheria). 
Plate  30. — Diphtheria  of  the  Conjunctiva. 
Plates  31,  32.— Tracheotomy. 
Pi^TE  33. — Low  Tracheotomy. 
Plate  34. — Fig.  L — Confluent  Bronchopneumonia. 

Fig.  2. — Bronchitis  and  Beginning  Bronchopneumonia. 
Plate  35. — Fig.  1. — Aphthous  Stomatitis  and  Beginning  Ulcerative 
Stomatitis. 

Fig.  2.— Thrush  of  the  Oral  Cavity. 
Plate  36. — Noma  of  the  Cheek. 
Plate  37. — Fig.  l.--The  Stool  of  Melena  Neonatorum. 

Fig.  2. — Dyspeptic  Stool  of  a  Breast-fed  Child. 
Plate  38.— Fig.  1.— The  Stool  of  Intestinal  Catarrh. 

Fig.  2.— The  Stool  of  Infectious  Colitis. 
Plate  39. — Prolapsus  Recti. 

Plate  40. — Universal  Seborrhea  (Cutis  Sebacea,  Congenital  Ichthy- 
osis). 
Plate  41. — Pemphigus  Neonatonmi. 
Plate  42. — Pemphigus  Syphiliticus  (Exanthema  Papulo-vesico-pustu- 

losum). 
I*LATE  43. — Chronic  General  Eczema. 
Plate  44. — Crusta  Lactea. 
Plate  45. — Impetigo  Contagiosa. 
Plate  46. — Erythema  Exudativum  Multiforme. 
Plate  47. — Lichen  Scrofulosorum. 
Pl.\te  48. — Scabies. 


CONTENTS 


PAGE 

Anatomic  Peculiakities 17 

The  Fetal  Circulation 17 

The  Skeleton 18 

Internal  Organs 23 

Physiologic  Pkculiarities 28 

Growtli  in  Length                     28 

Skull  and  Chest  Measurements 29 

Increase  in  Weight 30 

Digestion 37 

NOURISHMEXT 39 

Natural  Feeding 39 

Artificial  Feeding 44 

Freeing  Milk  of  Foreign  Material  and  Ricteria 45 

Equalizing  the  Cheniicophysical    Differences   According  to 

Various  ]Metliods 46 

Examination  and  History 49 

Anamnesis 50 

The  Proper  Methotl  of  Examining  a  Child 51 

Inspection 55 

Palpation •    •    •  58 

Auscultation 63 

Percussion 63 

Mensuration 66 

Secretions  and  Excretions 67 

General  Management  of  Disease  in  Children 68 

Dietetic  Treatment 68 

Hydrotherapy 69 

Medicinal  Treatment         71 

Diseases  of  the  Newborn 75 

General  Loss  of  Vitality  and  Premature  Birth 75 

Diseases  of  the  Umbilicus 81 

9 


10  CONTENTS 

DlSEA>SES  OF  THE  NEWBORN. 

Diseases  of  tlie  Umbilicus.  page 

Treatment  of  the  Normal  Umbilicus 81 

Congenital  Umbilical  Hcmia 81 

Acquired  Umbilical  Hernia 81 

Umbilical  Hemorrhage 84 

Umbilical  Fungus.     Umbilical  Growths 84 

Infection  of  the  Umbilicus 85 

Sepsis  of  the  Newborn 86 

Blennorrhea  Neonatorum,  Ophthalmia  Neonatorum  ...    88 

Tetanus  Neonatorum 90 

Helena  Neonatorum 93 

Acute  Hemoglobinuria      94 

Blood-tumor  of  the  Head.     Cephalhematoma 94 

Mastitis  Neonatorum 95 

Malformations 96 

Malformations  fronj  Arrested  Development,  Monstra  per 

Defectum 96 

Deformities  of  the  Extremities 108 

Constitutional  Diseases 114 

Rachitis 114 

Symptoms 114 

Direct  Kesultij  of  Disease  of  Skeleton 120 

Phenomena   which  are  Not  Directly   Due  to   Disease  of 

Skeleton 120 

Etiology 122 

Normal  Ossification 122 

Pathologic  Anatomy 124 

Diagnosis     .        127 

Treatment 129 

Congenital  Disturbances  in  Bone  Development 130 

Barlow's  Disease 137 

Diseases  of  the  Thymus  Gland 1 38 

Struma 138 

Basedow's  Disease      139 

Hypothyroidism 139 

Dysthyroidism 139 

Obesity 116 

Hemorrhagic  Diathesis.     Purpura 140 

Simple  Pnrpuni      146 

Bheumatic  Purpura  (Peliosis)  •       147 


CONTENTS  11 

Constitutional  Diseases. 

Hemorrhagic  Diathesis.     Purpura.  page 

Hemorrhagic  Purpura 147 

Abdominal  (Henocli's)  Purpura 147 

Fulminating  Purpura .    -  148 

Treatment  of  Purpura 148 

Anemia 149 

Chlorosis 150 

Treatment  of  Anemia  and  Chlorosis 150 

Splenic  Anemia  :  Infantile  Pseudoleukemia 151 

Chronic  Infectious  Diseases 152 

Hereditary  or  Congenital  Syphilis :  Heredosyphilis  ....  152 

Tuberculosis 168 

Peculiarities .  170 

Symptoms  of  General  Tuberculosis 172 

Tuberculosis  of  the  Bronchial  Nodes 173 

Scrofula 174 

Treatment  of  Tuberculosis  and  Scix)fula 178 

Tuberculosis  of  the  Lungs 180 

Tuberculous  Pleurisy 183 

Tuberculous  Pericarditis 184 

Abdominal  Tuberculosis  ...        184 

Tuberculous  Meningitis 187 

Tuberculosis  of  the  Bones  and  Joints 194 

Spina  Ventosa .  196 

Spondylitis.     Tuberculous  Caries  of  Vertebrae    ....  196 

Coxitis 198 

Tuberculosis  of  the  Knee-joint 201 

Tuberculosis  of  the  Joints  of  the  Feet 203 

Tuberculosis  of  the  Elbow 203 

Diseases  of  the  Nervous  System 204 

Diseases  of  the  Brain  and  its  Membranes 204 

Cerebrospinal  Meningitis 204 

Purulent  Meningitis 206 

Serous  Meningitis.     Meningisraus 207 

Thromlx)sis  of  the  Cerebral  Sinuses 207 

Circulatory  Disturbances  of  the  Brain 208 

Hyperemia 208 

Anemia 209 

Clinmic  IIydi"ocephalus 209 

Encei)halitis 217 


12  CONTENTS 

Diseases  of  the  Nervous  System. 

Diseases  of  tlie  Brain  and  its  Membranes.  page 

Cerebral  Infantile  Palsy 217 

Tumors 224 

Disea.ses  of  the  Spinal  Cord 225 

Spinal  Infantile  Paralysis 225 

Transverse  Myelitis 229 

Friedi-eich's  (Hereditaiy)  Ataxia 230 

Spastic  Spinal  Paralysis 230 

Functional  Nervous  Diseases 230 

Eclampsia 230 

Tetany ' 233 

Pseudotetanus 236 

Laryngospasra 236 

Spasmus  Nutans 239 

Salaam  Convulsions 239 

Congenital  Myotonia 239 

Peripheral  Paralyses 240 

Chorea  Minor 240 

Epilepsy 242 

Nervousness 245 

Neui-asthenia 245 

Hysteria 246 

Night  Terrors 248 

Masturbation 248 

Psychoses 249 

Imbecility 249 

Amaurotic  Idiocy  of  Families    ...        249 

Moral  Insanity       .        250 

Juvenile  Insanity 250 

Primary  Progressive  Myopathy 250 

Acute  Infectious  Disease.^ 252 

General  Discussion 252 

Measles 256 

Rubella .261 

Scarlet  Fever 262 

Small-pox 267 

Varicella .    .  273 

Diphtheria      275 

Typhoid  Fever .292 

Influenza .    .  294 


CONTENTS  13 

Acute  Infectious  Diseases.  page 

Whooping-cough 296 

Mumps 299 

Diseases  of  the  Circulatory  Apparatus 303 

General  Considerations 303 

Congenital  Heart  Disease 305 

Pericai-ditis 307 

Endocarditis 309 

Myocarditis 311 

Fatty  Degeneration  of  Heart  Muscle 311 

Diseases  of  the  Blood-vessels  ...        312 

Lymphadenitis ' 3J2 

Diseases  of  the  Kespiratory  Organs 315 

General  Discission 315 

Acute  Rhinitis 315 

Chronic  Rhinitis  and  Ozena 316 

Acute  Laryngitis  and  Pseudocroup 318 

Papilloma  of  Larynx 322 

Foreign  Bodies  in  the  Air-passages 322 

Hypei-plasia  of  the  Thymus  Gland 323 

Nervous  or  Bronchial  Asthma 323 

Acute  Tracheitis  and  Bronchitis 324 

Chronic  Bronchitis 326 

Capillary  Bronchitis 326 

Bronchopneumonia 328 

Croupous  Pneumonia 333 

Chronic  Pneumonia 335 

Pleurisy 337 

Diseases  of  the  Digkstivk  Orgaks 342 

Disea.ses  of  the  Mouth  and  Pharynx 342 

General  Discussion 3-12 

Bednar's  Aphthae 342 

Stomatitis 342 

Thrush 345 

Noma  .        346 

Angina 347 

Hypei-plasia  of  the  Lymph-tissue  of  the  Pharynx      .    .    .  349 

Retropharyngeal  Abscess 353 

Grastro-intestinal  Diseases 354 

General  Discussion 354 

Dyspepsia 360 


14  CONTENTS 

Diseases  of  the  Dioestive  Organs. 

Gastrointestinal  Diseases.  page 

Intestinal  Cat^irrh 361 

Cholera  Infantum 362 

Intestinal  Inflammations  .    .        363 

Chronic  Anections 365 

Atrophia  Infantum 366 

Atony  of  the  Stomach  and  Intestines 374 

Appendicitis ...  375 

Congenital  Stenoses  and  Atresise  of  the  (Jastro-intestinal 

tract 375 

Intestinal  Invagination 380 

Intestinal  Parasites 380 

Diseases  of  the  Liver «  .    .    .  383 

Icterus 383 

Acute  Peritonitis   .        • 383 

Chronic  Peritonitis 383 

Diseases  of  the  Genito-urinary  Tract 385 

Diseases  of  the  Kidneys 385 

Genenil  Discussion 385 

Albuminuria 385 

Hematuria  and  Hemoglobinuria •  .    .  387 

Acute  Parenchymatous  Nephritis 388 

Chronic  Nephritis 390 

Urinary  Concretions 391 

Pyelitis 394 

Hydronephrosis 395 

Disea.ses  of  the  Bladder  and  Sexual  Organs 395 

Pollakiuria  and  Enuresis 395 

Cystitis 396 

Preputial  Epithelial  Adhesion 398 

Phimosis 398 

Hypospadias.     Epispadias 400 

Undescended.  Testes 400 

Hydrocele 402 

Cellular  Atresia  of  the  Vulva ....  403 

Vulvovaginitis.    Gangrene  and  Phlegmasia  of  tiie  Vulva  .  404 
Diseases  of  the  Skin 406 

General  Discussion 406 

Nevi 406 

Seborrhea 408 


CONTENTS  15 

Diseases  of  the  Skin.  page 

Ichthyosis 411 

Pemphigus  Neonatorum 414 

Dermatitis  Exfoliativa 415 

Sclerema  Neonatorum 417 

Eczema ' 419 

Prurigo 425 

Erythema  Exudativum  Multiforme  and  Erythema  Nodo- 
sum   426 

Lichen  Urticatus 428 

Urticaria 428 

Lichen  Scrofulosorum 429 

Herpes 430 

Scabies 431 

Pediculosis  Capillitii 432 

Herj>es  Tonsurans 433 

Folliculitis  Abst;edens 433 

Index 437 


DISEASES  OF  CHILDREN 


GENERAL  PART 

The  fact  that  certain  diseases  are  j^eciiliar  to  infants 
and  that  many  of  the  diseases  of  adult  life  assume  an 
altogether  diflierent  character  in  children,  de|HMuls  less 
upon  ditferenees  in  causation  than  upon  the  difference  in 
the  region  attacked  by  the  disease  process.  A  thorough 
knowknlge  of  the  construction  and  function  of  the  infan- 
tile body  is  absolutely  necessary  in  order  to  understand 
the  diseases  of  children.  In  general,  the  bmly  of  a  child 
is  characterized  by  its  diminutive  size,  by  its  diminished 
resistance,  and  the  consequent  hypersensitiveuess  of  the 
organs,  by  increase  in  growth  and  alterations  in  form, 
together  with  the  associated  variations  of  the  physiologic 
functions  and  reactions  of  the  organs. 

ANATOMIC  PECULIARITIES 

THE  FETAL  CIRCULATION 

The  blood  circulates  through  the  fetus  as  follows : 
From  the  placenta  through  the  umbilical  vein  ;  the  latter 
divides  into  two  branches  at  the  liver,  one  empties  into 
the  portal  vein  and  the  other,  as  the  ductus  venosus 
Arantii,  into  the  inferior  vena  cava.  This  vessel  in  turn 
empties  into  the  right  auricle,  whence  the  blood  is  guided 
by  means  of  the  Eustachian  valve  through  the  foramen 
ovale  directly  into  the  left  auricle.  The  l)lood  then  tlows 
into  the  left  ventricle,  the  aorta,  the  major  circidation,  and 
in  part  through  the  hypogastric  and  umbilical  arteries,  to 
be  aerated  in  the  placenta.     The  blood  from  the  superior 


18  ANATOMIC  PECULIARITIES 

FIGURE  I 

Circulation  in  the  Fetus.— 1.  Umbilical  vein.  2.  Branches  of  the 
portal  vein.  3.  Ductus  veuosasArantii.  4.  Inferior  vena  cava.  5.  Aorta. 
6.  Hypogastric  arteries.  7.  Umbilical  arteries.  8.  Superior  vena  cava. 
9.  Pulmonary  artery.    10.  Ductus  arteriosus  JJotalli. 

vena  cava  flows  into  the  right  auricle,  and  passing  tlie 
blood  current  from  the  inferior  vena  cava,  enters  the 
right  ventricle  and  the  pulmonary  artery  ;  from  here  only 
a  small  portion  of  the  blood  enters  the  lungs,  while  the 
greater  portion  passes  through  the  ductus  arteriosus  Botalli 
into  the  aorta.  Thus  the  fetus  receives  none  but  mixed 
bloofl,  for  together  with  the  blootl  from  the  umbilical  vein, 
the  liver  also  receives  blood  which  has  already  been  used 
from  the  portal  vein.  The  liver,  the  head,  and  the  upper 
extremities  are  supplied  with  blood  richly  laden  with 
oxygen,  while  the  lower  half  of  the  body  receives  blood 
poor  in  oxygen.  The  blood  in  the  lungs  is  purely 
venous. 

After  birth  the  expansion  and  congestion  of  the  lungs 
causes  the  pressure  in  the  left  auricle  to  lessen  and  to 
equal  that  of  the  right  auricle,  on  account  of  which  the 
foramen  ovale  closes.  The  ductus  arteriosus  Botalli 
receives  less  blood,  and  the  change  in  the  position  of  the 
lungs  causes  it  to  become  constricted,  thronibo.sed,  and 
obliterated.  The  three  umbilical  vessels  and  the  ductus 
Arantii  likewise  become  obliterated  on  account  of  cessa- 
tion of  the  blood  current  after  the  maternal  and  fetal 
bodies  are  separated. 

THE  SKELETON 

The  skeleton  during  early  infancy  is  soft,  easily  de- 
formed, and  is  undeveloped. 

Skull. — In  the  newborn  infant  the  cranial  is  much 
larger  than  the  facial  portion  of  the  skull ;  and,  therefore, 
the  palate  and  nose  are  very  narrow  and  the  facial  mus- 
culature but  poorly  developed.  Body  equilibrium  has 
not  yet  been  established,  and  the  skull  when  at  rest  falls 
backward   in   the   newborn,   instead    of  forward    as   in 


Fig.    1. 


THE  SKELETON  19 

adults.  The  face  gradually  reaches  full  development 
tlirough  the  growth  of  the  upper  and  lower  jaws,  espe- 
cially the  ascending  rami  of  the  inferior  maxilla  and  the 
alveolar  processes,  and  through  eruption  of  the  teeth  and 
elevation  of  the  bridge  of  the  nose.  The  cranium  is 
still  wide  open  at  the  anterior  fontanel ;  the  latter  is 
formed  by  the  frontal  and  parietal  bones,  is  rhomboidal 
in  shape,  with    the   acute   angle   pointing  forward,  and 


Fig.  2. — Tliorax  of  a  newl)orii  infant.  Funnel-shaped,  horizontal  upper 
aperture;  at  full  inspiration.  iFioni  a  preparation  iu  the  Anatomic 
Institute  in  Munich.) 

closes  in  the  twelfth  to  the  fifteenth  [in  exceptional  cases 
as  late  as  the  twentieth  to  the  twenty-fourth]  month  after 
birth.  The  small  fontanels  between  the  parietal  and 
occipital  bones  are  represented  after  birth  only  by  a  sujx^r- 
iicial  depression,  while  the  anterior  and  posterior  lateral 


20  ANATOMIC  PECULIARITIES 

PLATE  I 

The  Skulls  of  a  Newborn  Infant,  of  a  Six-year-old  CUld,  of  an 
Adult  Man,  and  of  an  Old  Man.— The  different  relationships  between  the 
cranial  and  facial  portions  of  tlie  skull  are  shown,  also  the  gradual  eleva- 
tion of  the  face,  tiie  development  of  the  ascending  rami  of  the  lower  jaw, 
and  the  similarity  between  the  infantile  skull  and  that  of  old  age.  (From 
preparations  in  the  Anatomic  Institute  in  Munich.) 

PLATE  2 

Skulls  of  a  Newborn  Infant  (from  in  front  and  from  above),  of  a 
Six-year-old  Child,  and  of  a  Man.— Showing  the  persistence  of  the  fon- 
tanels and  the  sutures,  and  the  development  of  the  facial  portion  of 
the  skull.     (From  preparations  in  the  Anatomic  Institute  in  Munich.) 

fontanels  are  completely  closed.  The  anterior  are  formed 
by  the  junction  of  the  frontal,  temporal,  and  sphenoid 
bones;  the  posterior  by  union  of  the  parietal,  temporal, 
and  occipital  bones.  The  sutures  are  loose  or  still  gape 
somewhat. 

Thorax. — The  thorax,  which  is  circular  on  cross-.section, 
approaches  more  nearly  the  shape  of  a  funnel  than  that 
of  a  cylinder.  The  anterior  wall  is  higher  and  a  greater 
distance  from  the  spinal  column  than  in  the  adult ;  this 
is  the  inspiratory  or  emphy.sematous  posture.  The  upper 
aperture  and  the  ribs  lie  in  a  horizontal  position.  The 
anterior  wall  gradually  descends  and  the  sagittal  diameter 
becomes  smaller  on  account  of  the  weight  of  the  hanging 
arm,  tension  of  the  abdominal  muscles,  and  the  relative 
diminution  of  the  liver  and  spleen. 

The  transverse  .section  loses  its  circular  form  and 
becomes  oval  in  shape,  the  lateral  being  longer  than  the 
anteroposterior  diameter.  (Asthmatics  possess  a  perma- 
nent infantile  form  of  thorax.) 

Pelvis. — The  pelvis  is  still  largely  cartilaginous  and 
highly  movable.  The  promontories  are  only  partially 
developed  and  the  po.sition  is  more  horizonal.  The  devel- 
opment of  the  pelvis  proceeds  with  apposition  at  the  sym- 
physes, at  the  lateral  processes  of  the  .sacrum,  and  at  the 
synchoudro.ses  of  the  ilium,  os  pubis,  and  .sacrum,  as  well" 
as  the  forward  growth  of  the  promontory  of  the   sacrum. 

Vertebra. — Aside  from  the  promontories  the  sub.sequent 


Tab.  I 


Tab.  2 


THE  SKELETON 


21 


curvatures  of  the  spine  are  still  absent  or  only  indicated, 
and  the  vertebrae  appear  to  form  a  straight  line.  The 
final  shape  of  the  spine  is  due  to  the  weight  of  the  body 
and  the  traction   of  the  muscles.     Voluntary  raising  of 


Fig.  3. — Thorax  of  an  adult  man.  The  sternum  and  ribs  have 
descended  ;  the  upper  aperture  is  bent  downward  ;  the  sternum  is  nearer 
the  spinal  column.  (Preparation  from  the  Anatomic  Institute  in 
Munich.) 

the  head  in  from  two  to  three  months  forms  the  cervical 
curvature ;  the  standing  posture  at  about  the  twelfth 
month,  the  traction  of  the  erector  muscles  of  the  trunk. 


22 


ANATOMIC  PECULIARITIES 


and  the  weight  of  the  abdominal  organs  tend  to  increase 
the  lumbar  curvature.  The  weight  of  the  body  in  sitting, 
the  traction  of  the  shoulder  and  the  rectus  muscles,  help 
to  form  the  dorsal  curvature.  ' 


Fig.  4. — Thorax  of  au  adult  woman.  The  descent  of  the  anterior 
wall  of  the  thorax  is  even  more  pronounced  than  in  man.  (From  a  chart 
in  the  Anatomic  Institute  in  Munich.) 


Extremities. — Aside  from  the  undeveloped  state  of  the 
neck  of  the  humerus,  there  are  no  great  diiferences  in 
form ;  tlie  foot,  which  originally  is  poor  in  fat,  later,  in 


INTERNAL  ORGANS  23 

the  crawling  and  walking  period,  becomes  encased  in  fat, 
showing  the  same  skeletal  structure  as  in  the  adult 
(Spitzy).  The  epiphyses  of  the  long  cylindric  bones,  the 
hand,  and  the  tarsal  bones  are  still  cartilaginous ;  their 
ossification  is  not  completed  until  nearly  the  sixteenth 
year  (Rauber,  von  Ranke). 

The  body  surface  is  much  greater  than  in  adults;  to 
each  kilogram  [2.2  lbs.]  of  body  weight  there  are  810  sq. 
mm.  [12.5  sq.  in.]  of  surface  in  the  newborn,  620  sq.  mm. 
[9.6  sq.  in,]  in  infants  six  months  old,  450  sq.  mm.  [6.9  sq. 
in.]  in  seven-year-old  children,  and  320  sq.  mm.  [4.9  sq. 
in.]  in  adults. 

INTERNAL   ORGANS 

The  Thymus  Gland. — This  organ,  occurring  only  in 
children,  lies  in  the  anterior  mediastinum  and  is  con- 
cerned in  the  formation  of  blood.  Its  size  varies  in 
individuals  of  the  same  age  ;  it  is  from  2  to  7  cm.  [.8-1.4 
in.]  in  width  and  from  5  to  10  cm.  [2-4  in.]  in  length, 
and  weighs  in  the  newborn  on  an  average  12  gm.  [191 
gr.].  The  gland  continues  to  grow  during  the  first  year 
of  ife,  after  which  it  diminishes  in  size  on  account 
of  atrophy  of  the  glandular  substance,  which  is  replaced 
by  connective  tissue,  and  disappears  at  the  time  of 
puberty. 

The  Liver. — This  organ  is  relatively  larger  and  heavier 
than  in  adults.  It  weighs  in  newborn  and  nursing 
infants  one-twentieth  of  the  body  weight,  whereas  in 
adults  it  weighs  only  one-fiftieth  of  the  total  weight  of 
the  body.  The  lower  edge  runs  obliquely  from  the  crest 
of  the  right  ilium  above  the  umbilicus  toward  the  left  to 
the  region  of  the  fundus  of  the  stomach.  The  left  lobe 
reaches  the  left  anterior  axillary  line. 

The  Kidneys. — These  are  lobulated  and  comparatively 
large.  The  histologic  structure  of  the  liver,  kidneys,  and 
pancreas  at  the  time  of  birth  is  still  in  a  transitional 
stage  of  the  process  concerned  in  the  formation  of  a  definite 
structure.  The  liver  and  kidneys  probably  still  possess 
for  a  time  after  birth  the  fetal  blood-producing  function. 


24  ANATOMIC  PECULIARITIES 

Fig.  5. — Median  sectiou  of  a  newborn  infant.  Aside  from  a  slight 
promontory  curvature,  the  vertebrse  still  form  an  almost  perfectly 
straight  line.    (From  a  preparation  in  the  Munich  Gynecologic  Clinic.) 

Fig.  6. — A  median  frozen  section  through  the  body  of  a  six-year-old 
boy.  The  vertebral  column  shows  a  slight  cervical  and  dorsal  curvature 
and  a  fairly  well-developed  promontory.  The  spine  is,  however,  still  quite 
straight,  especially  in  the  lower  dorsal  and  lumbar  portion.  A  physio- 
logic lumbar  lordosis  is  distinctly  marked  in  life  (J.  Symington). 

Fig.  7. — Median  section  through  the  skeleton  of  an  adult  man.  The 
curvatures  of  the  spinal  column  are  fully  developed  ;  the  anterior  wall 
of  the  thorax  has  descended  and  the  pelvis  tilted.  (Preparation  in  the 
Anatomic  Institute  of  Munich.) 


The  Stomach. — The  stomach  occupies  a  more  vertical 
position,  the  fundus  is  but  slightly  formed,  and  the 
musculature,  especially  about  the  cardia,  is  but  poorly 
develo})ed.  The  normal  position  and  shape  are  developed 
in  the  course  of  the  first  year.  The  mucosa,  with  its  rich 
blood  supply,  is  more  sensitive  to  thermal  and  chemic 
irritants,  which  together  with  the  position  of  the  organ, 
the  small  fundus,  and  weakness  of  the  cardia,  all  explain 
the  tendency  of  the  infant  to  vomit.  The  capacity  of  the 
stomach  is  increased  from  about  40  ccm.  [1.3  oz.l  at  the 
time  of  birth  to  from  300  to  400  ccm.  [10-13.5  oz.J  at  the 
end  of  the  first  year  of  life. 

The  Intestines. — The  length  of  ^he  intestines  in  nursing 
infants  is  six  times  that  of  tiie  body,  whereas  in  adults  it 
is  only  four  and  a  half  times  the  body  length.  The  ca- 
pacity in  the  new  born  is  5000  ccm.  [10  ])ints],  in  twelve- 
year-old  children  9000  ccm.  []8|  pints],  and  in  adults 
only  4000  ccm.  [13  pints]  to  1  kilogram  of  body  weight. 
The  mucosa  is  sensitive  and  contains  incompletely  de- 
veloped glands.  The  weakness  of  the  musculature  favors 
constipation  and  explains  the  frequent  tendency  to  dilata- 
tion and  enteralgias.  The  intestines  possess  a  great 
absorptive  capacity,  but  relatively  deficient  digestive 
power.  The  colon  runs — without  an  hepatic  flexure  par- 
allel to  the  edge  of  the  liver — obliquely  from  the  right 
iliac  crest  upward  toward  the  left. 

The  Nervous  System. — The  dura  is  attached  to  the 
cranium.     The  brain  is  large  and  heavy  and  equals  13  to 


Fig.  5. 


Fig.  6. 


26 


Fio.  7. 


27 


28 


PHYSIOLOGIC  PECULIARITIES 


14  per  cent,  of  tho  body  weight,  in  contradistinction  to 
2.7  per  cent,  in  adults.  It  grows  very  rapidly  during 
tiie  first  year,  at  the  end  of  which  time  it  reaches  one- 
half  of  its  permanent  weight.  The  convolutions  are  but 
slightly  differentiated  and  there  are  but  few  medullated 
nerve-fibers.  The  psychomotor  subcortical  inhibitory 
centers  are  but  slightly  excitable,  as  are  also  the  per- 
ipheral sensory  and  motor  nerves  during  the  first  six 
weeks  (Soltmann,  Westphal). 

The  musculature  is  relaxed,  pale,  watery,  and  is  readily 
fatigued. 

The  adipose  tissue  is  present  in  large  amounts.  In  the 
cheeks,  where  it  possesses  distinct  anatomic  boundaries,  it 
forms  a  cushion  of  fat,  and  is  of  assistance  in  the  act  of 
sucking  (von  Ranke).  When  the  baby  begins  to  walk 
about  he  loses  much  of  this  fat ;  that  of  the  cheek  is  the 
last  to  disappear. 

Female  Genitals. — These  are  not  closed'.  The  labia 
minora,  hymen,  and  urethra  are  visible,  and  therefore 
the  infant  is  predisposed  to  vulvovaginitis  and  cystitis. 


PHYSIOLOGIC   PECULIARITIES 
GROWTH  IN  LENGTH 

The   average    length  of  a  newborn  infant   is  50  cm. 

E20  in.],  in  boys  51  cm.   [20.2  in. J  and  in  girls  49  cm. 
19.8  in.].      The  length   of  the  body  at  various   ages, 
according  to  E.  von  Jjange,  is  as  follows: 


Age  in) 
months/ 
Body  ) 
length  > 
(cm.)  I 
[Body  ) 
length  V 
(in.)]    i 


Birth. 

I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

49.5 

55.2 

68.5 

61.0 

6.3.0 

64.7 

66.2 

67.5 

68.8 

69.9 

71.0 

72.0 

19.8 

22.0 

23.4 

24.4 

25.2 

25.8 

26.4 

27.0 

27.5 

27.9 

28.4  28.8 

XII. 
73.0 

29.4 


The  increase  in  the  length  of  the  body  is  practically 
the  same  for  both  boys  and  girls  during  the  first  two 
years,  but  from  then  until  the  thirteenth  year  the  female 
child  grows   more   slowly.     After   the    thirteenth  year, 


SKULL  AND  CHEST  MEASUREMENTS 


29 


however,  because  of  their  earlier  period  of  puberty,  girls 
grow  more  rapidly  and  overtake  the  gain  made  by  the 
males  previous  to  that  time.  After  its  fifteenth  year, 
however,  the  female  child  grows  less  in  length  than  the 
male. 

During  the  first  year  the  child  grows  about  23  cm.  [9.2 
in.]  ;  in  the  second  year,  about  10  cm.  [4  in.]  ;  in  the  third 
year,  8  cm.  [3.2  in.],  and  in  the  fourth  year,  7  cm.  [2.8 
in.].  In  four  years  it  has  doubled  its  growth  and  in  four- 
teen years  trebled  it. 


Body  Length,  AGcording  to  E.  von  Lange 


Age  in  years. 

Boys. 

Girls. 

1 

73.0 

73.0 

2 

83.1 

83.1 

3 

91.5 

91.3 

4 

99.0 

98.7 

5 

105.4 

105.0 

6 

1112 

110.7 

/ 

116.5 

116.0 

8 

121.5 

120.9 

9 

126.2 

125.6 

Age  in  years. 

Boys. 

10 

130.7 

11 

135.0 

12 

139.2 

13 

143.8 

14 

149.7 

15 

156.7 

16 

163.5 

17 

167.6 

18 

169.4 

Girls. 


130.0 
134.6 
140.3 
147.6 
153.8 
157.3 
159.0 
159.7 
159.9 


SKULL  AND  CHEST  MEASUREMENTS 

Of  the  skull  measurements  the  frou to-occipital  periph- 
ery is  to  be  measured  over  the  most  prominent  portion 
of  the  froutiil  and  occipital  bones.  Aside  from  this 
moa.surement,  in  the  case  of  cranial  disease,  the  following 
distiinces  are  to  be  measured  :  The  bitemporal  from  one 
external  ear  to  the  other;  the  fronto-occipital  diameter 
from  the  glabella  to  the  occipital  protuberance ;  the 
biparietal,  from  one  parietal  protuberance  to  the  other. 
The  circumference  of  the  chest  is  taken  midway  between 
inspiration  and  expiration  while  the  arms  are  held  in  a 
horizontal  position. 

The  circumferences  of  the  skull  and  chest  increase 
symmetrically  until  about  the  fifth  year,  but  after  tliat 


[14.1 

in.l 

17.0 

18.4 

((  • 

[19.2 

20.0 

'20.0 

"1 

[20.5 

"1 

[20.9 

"] 

34.2  cm 

.  [13.6  in.] 

41.0    " 

16.4  "  ■ 

46.0    " 

18.4  " 

47.3    " 

18.9  "  ■ 

49.0    " 

19.6  " 

52.0   " 

20.8  " 

58.0    " 

23.2  "  ■ 

65.0    " 

[26.0  "  ] 

30  PHYSIOLOGIC  PECULIARITIES 

time  the  chest  grows  more  rapidly.  It  is  to  be  noted 
that  the  circumference  of  the  chest  usually  exceeds  one- 
half  of  the  body  length  by  from  9  to  10  cm.  [3.6-4  in.]. 

Head  and  Chest  Measurements  (Heubner) 

Age.  Circumference  of  bead.      Circumference  of  chest- 

1  month 35.4  cm. 

6  months 42.7  " 

1  year 45.6  " 

2yeai-8 48.0  " 

4  veai-s 50.0  " 

5  yeai-s 50.0  " 

8  yeara 51.3  '* 

12  yeare 52.3  " 

INCREASE  IN  WEIGHT 

The  average  weight  of  a  newborn  infant  is  3250  gra. 
(extremes  2500-4000  gm.  and  over),  boys  weighing  a  little 
more  than  girls.  The  physiologic  loss  of  weight  during 
the  first  three  or  four  days  equals  about  200  gm.  This 
depends  upon  tiie  lack  of  proportion  between  ingestion 
and  excretion  ;  discharge  of  meconium  and  urine,  excre- 
tion through  skin  and  lungs,  and  the  small  amount  of 
nutritive  material  ingested.  In  from  five  to  eight  days 
the  original  weight  is  usually  regained. 

The  weight  of  the  body  increases  steadily  or  intermit- 
tently with  diminishing  rapidity. 

The  daily  increase  in  weight  is  originally  30  gm.  ;  but 
after  a  year  only  about  10  gra.  There  is,  as  a  rule,  a  loss 
of  weight  during  the  ninth  month  of  life  (dentition, 
change  of  nutrition)  and  in  the  first  year  of  school  life. 
At  the-end  of  five  months  the  weight  is  about  double  the 
original  weight ;  after  a  year,  three  times  ;  after  six  years, 
six  times  ;  and  after  the  thirteenth  to  the  fourteenth  years, 
twelve  times  the  weight  at  birth.  Bottle-fed  infants 
weigh  less  than  breast-fed  children  up  to  nine  months  of 
age,  but  after  that  time  soon  regain  this  loss  and  later 
show  no  difference. 


INCREASE  IN  WEIGHT  31 

Tables  of  Weights,  AGCording  to  Heuhner 


(a)  First  year  of  life  (breast-fed  infants). 

Gm. 

Original  weij 
End  of  4th  w 

rht 

3433 

eek  ....           .    . 

4008 

End  of  8th 
End  of  12th 

(1 

4907 
5600 

End  of  16th 

<( 

6294 

End  of  20th 

(1 

6824 

End  of  24th 

n 

7289 

End  of  28th 

11 

7774 

End  of  32d 

.i 

8175 

End  of  36tli 

(( 

8655 

p]nd  of  40th 

I( 

8855 

End  of  44th 

l( 

9232 

End  of  48th 

« 

9589 

End  of  52d 

10141 

(6)  Between  2  and  18  years  of  age. 


At  the  end  of  2  years  . 
At  the  end  of  3  yeare  . 
At  the  end  of  4  years  . 
At  the  end  of  5  yeai-s  . 
At  the  end  of  6  yeai-s  . 
At  the  end  of  7  yeare  . 
At  the  end  of  8  yeai-s  . 
At  the  end  of  9  years  . 
At  tlie  end  of  10  yeare 
At  tlie  end  of  11  yeare 
At  the  end  of  12  years 
At  the  end  of  13  years 
At  the  end  of  14  yeare 
At  the  end  of  15  yeai-s 
At  tlie  end  of  16  years 
At  the  end  of  17  years 
At  the  end  of  18  years 


Boys. 

13.2 

ks. 

15.4 

u 

16.8 

(( 

19.3 

<( 

21.1 

i( 

23.0 

(( 

24.9 

a 

26.8 

(( 

29.4 

« 

32.1 

(( 

34.9 

(1 

38.2 

i( 

42.6 

« 

51.0 

(( 

57.1 

« 

62.7 

« 

66.0 

(( 

Girls. 


12.0  kg. 

14.0  " 

15.7  " 

17.5  " 

19.0  " 
20.7  " 

22.5  " 
24.9  " 
26.4  " 

29.1  " 
33.7  " 
37.9  " 

42.6  " 

47.2  " 
48.2  " 
49.2  " 
50.0  " 


Tiie  increase  in  length  and  weight  are  not  proportion- 
ate. During  the  period  of  active  body  growth  the  in- 
crease in  height  exceed.s  that  of  the  weight  (Axel  Key). 
During  the  summer  there  is  usually  a  decided  increase  in 
height,  but  only  a  slight  increase  in  weight,  whereas 
during  winter  the  reverse  holds  true  (Mailing,  Hansen). 


32 


PHYSIOLOGIC  PECULIARITIES 


Table  of  the  Average  Height,  Weight,  Head  Circumfer- 
ences, and  Chest  Measurements  of  American  Boys 
and  Girls.     (From  Koplik.) 


Years 
of  age. 


5J 
6J 
7J 
8J. 
9i. 
lOi  . 

m 

12i 
13i 
14J 
15J 


Sex. 


Boys 
Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
Girls 
Bovs 
Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
Girls 
Boys 
Girls 


Height. 


In. 
41.7 
41.3 
43.9 
43.3 
46.0 
45.7 
48.8 
47.7 


Cm. 
105.9 
104.9 
111.9 
109.0 
116.8 
116.0 
123,9 
121.1 


Weight. 


50.0|  127.0 
49.7  126.2 
51.9,  131.8 
50.7:  131.3 
53.6!  136.1 
53.8,  1.36.6 
55.4  140.7 
56.1  142  5 
.57.5  146.0 


.58.5 
60.0 
60.4 
162.9 
161.6 


148.6 
152.3 
153.4 
159.7 
156.4 


Lbs. 
41.6 
40.7 
45.2 
43.4 
49.5 
47.7 
54.5 
•52.5 
59.6 
.57.4 
65.4 
62.9 
70.7 
69  5 
76.9 
78.7 
*4.8 
88.7 
95.2 
98.3 
107.4 
106.7 


Kg. 

18.9 
!l8.5 
,20.5 

19.5 


Head 
circum- 
ference. 


In 

20.1 
19.7 
20.2 
19.8 


22.5  20.4 

21.6  20.0 
24.4!  20.5 
23.8  2f).2 
27.0,  20.6 
26.0 !  20.4 


29.5 
28.5 
32.2 
31.5 
34.9 
35.7 
38.5 


20.6 
20.5 
20.8 
20.7 
21.0 
20.9 
21.1 


40.3  21.0 
43.2  21.3 
44.6  21.3 
48.8  21.4 
48.51 21.5 


Cm. 
51.2 
50.2 
51.5 
50.3 
51.9 
50.9 
52.2 
51.2 
62.4 
51.9 
52.6 
52.0 
52.9 
52.5 
53.3 
.^-3.0 
.53.5 
.53.5 
54.1 
54.1 
54.5 
54.6 


Depth 
of  chest. 


Cm. 
12.3 
12.3 
12.8 
12.3 
12.9 
12.5 
12.8 
12  5 
13.2 
13.1 
13.2 
13.0 
13.8 
13.1 
14.1 
13.8 
14.3 
14.1 
15.0 
14.5 
16.0 
15.3 


Breadth 

Chest 

of  chest. 

expan- 
sion. 

In. 

Cm. 

In. 

Cm. 

7.1 

18.1 

1.3 

3.4 

7.0 

17.7 

1.4 

3.5 

7,2 

18.4 

1,6 

4.2 

7.0 

17.7 

1.5 

3.8 

7.4 

18.9 

1.8 

4a 

7.2 

18.4 

1.8 

4.5 

7.6 

19.4 

2.3 

5.9 

7.4 

18.9 

2.0 

5.0 

7.8 

19.7 

2.5 

6.6 

7.0 

19.3 

2.2 

6.6 

8.0 

20.2 

2.7 

7.0 

7.8 

19.8 

2.4 

6.0 

8.2 

20.9 

2.9 

7.3 

8.0 

20.3 

2.6 

6.6 

8.5 

21.5 

3.0 

7.8 

8.4 

21.0 

2.4 

6.2 

87 

2'.>.1 

3.2 

8.2 

8.7 

22.1 

2.6 

6.6 

8.9 

22.7 

3.3 

8.4 

9.0 

22.9 

2.7 

6.8 

9.3 

23.6 

3.3 

8.4 

9.5 

23.8 

2.6 

6.5 

Table  of  Weight,  Length,  Head  Circumference,  and  Girth 
of  Chest  from  Birth  to  the  End  of  the  Fourth  Year. 
(From  Koplik.) 


Head 

Age. 

Sex. 

Length. 

Weight. 

circumfer- 
ence. 

Chest  girth. 

In. 

Cm. 

Lbs. 

Kg. 

In. 

Cm. 

In. 

Cm. 

Birth  ... 

Boys     .... 

19.7 

.500 

7.4 

3.45 

13.8 

3.5.1 

12.6 

32.0 

Girls    ... 

19.3 

49.0 

7.1 

13.1 

33.4 

11.8 

30.0 

6  mouths  . 

Boys     .... 

25.4 

64.8 

16.0 

72 

16.0 

40.5 

1.5.7 

39.9 

iGirls        .   .   . 

25,0 

6:!.6 

15.5 

70 

164 

41.7 

15.2 

38.6 

12  months  .  ■! 

Boys     ... 
Girls        ... 

29.5 

28.7 

73.8 
73.2 

21.5 
21.0 

9.8 
9.5 

17.8 
18.2 

45,3 
46.3 

17.8 
19.0 

45.1 
48.3 

2  years  .  .  | 

Boys            .   . 

33.8 

84.5 

30.3 

13.8 

19.3 

49.0 

20.0 

.50.8 

Girls     ... 

32.9 

82.8 

29.2 

13.3 

18.0 

456 

18.0 

48.0 

3  years  .  .  | 

Boys     .... 

37.0 

92.6 

34.9 

15.9 

19.3 

49.0 

20.1 

51.1 

Girls           .   . 

36.3 

907 

33.1 

1.5.0 

19.0 

48.4 

19.8 

.50.5 

4  years  .  .  | 

iBoys     .... 

39.3 

98.2 

37.9 

17.2 

19.7 

50.3 

20.7 

.52.8 

IGirls    .... 

,1 

38.8 

97.0 

36.3 

16.5 

19.5 

49.6 

20.5 

.52.2 

INCREASE  IN   WEIGHT  33 

Daily  Increase  in  Weight  in  Grams,  According  to  Camerer 


Week. 

Breast-fed  children. 

Artificially  fed  children. 

1 

20 

4 

2  to  12 

31  to  20 

21  to  22 

12  to  24 

24  to  18 

22 

24  to  3G 

15  to  16 

13tol6 

3G  to  40 

9 

9 

40  to  52 

12 

12 

Condition  of  the  Skin. — In  the  newborn  there  is  a  flesh- 
red  color,  and  a  physiologic  yellow  discoloration  frequently 
prevails  for  from  two  to  six  days.  In  the  course  of 
two  or  three  weeks  a  permanent  rose-red  color  develops. 

Icterus  neonatorum  occurs  in  80  per  cent,  of  the  new- 
born and  ])rogresses  without  discoloration  of  the  feces  and 
without  the  usual  bile-stained  urine.  The  conjunctivae 
are  slightly  yellow  and  the  jaundice  is  chiefly  limited  to 
the  upper  half  of  the  body.  Children  who  are  decidedly 
icteric  suffer  considerable  loss  of  weight  during  the  first 
week  of  the  disease  and  show  a  tendency  to  disturbances 
of  digestion.  Icterus  of  long  duration  usually  indicates 
the  existence  of  a  pathologic  condition  (syphilis  of  the 
liver,  obliteration  of  the  bile-ducts).  The  etiology  is  not 
yet  perfectly  understoo<l. 

The  skin  shows  during  the  first  weeks  an  increased  ac- 
tivity. There  is  nearly  always  a  certain  degree  of  exfoli- 
ation in  the  second  or  third  week,  often  accompanied  by 
swelling  and  redness,  especially  of  the  toes  and  fingers. 
There  is  an  increased  secretion  of  sebaceous  matter  from 
the  scalp,  with  the  formation  of  fatty  scales,  which  are 
composed  of  sebum  and  epithelium.  The  secretion  of 
sweat  is  slight,  but  in  the  case  of  rachitic  and  bottle-fed 
children  may  be  quite  profuse.  The  nodules  which  .<?ome- 
times  occur  in  the  skin  of  the  face  are  due  to  secretions 
from  the  sebaceous  glands  (Epstein)  and  disappear  in  the 
course  of  time. 

The  Blood  and  its  Circulation. — The  blood  does  not  reach 
its  definite  stage  of  development  until  the  fourth  or  fifth 
3 


34  PHYSIOLOGIC  PECULIARITIES 

year.  The  number  of  the  red  cells  as  well  as  the  white 
corpuscles  is  increased  during  the  first  year.  Two-thirds 
of  the  leukocytes  are  mononuclear  lymphocytes  and  only 
one-third  are  polynuclear  leukocytes  (Metchnikoff)  ;  it  is 
for  this  reason  probably  that  little  children  are  susceptible 
to  infections  (Heubner). 

The  blood  current  is  more  rapid  than  in  adults ;  it  takes 
12  to  15  seconds  to  complete  the  circulation  in  the  infant, 
whereas  22  seconds  are  required  in  the  adult. 

The  pulse  in  healthy  children  often  shows  irregularity 
in  force  and  frequency.  Even  slight  affections  may  cause 
a  disproportionate  increase  in  frequency.  The  average 
rate  during  the  first  six  months  is  130  per  minute  ;  at  the 
end  of  the  first  year,  120 ;  in  three  years  it  is  110,  and  in 
nine  years,  82  (girls  92). 

Respiration. — The  number  of  respirations  during  sleep 
averages  in  the  newborn  35.3 ;  in  the  second  year,  28  ; 
in  the  third  and  fourth  year,  25.  The  depth  of  the  in- 
spirations and  the  length  of  the  intervals  are  also  irregular 
in  sleep.  The  respiration,  on  account  of  the  inspiratory 
position  of  the  thorax  during  the  first  year,  is  chiefly 
diaphragmatic.  Not  until  the  tenth  or  twelfth  year  is  the 
adult  type  reached.  The  first  inspiratory  movement  follows 
irritation  of  the  respiratory  center  by  the  blood  which  has 
become  charged  with  COg  during  birth. 

Sleep. — A  child  sleeps  during  the  first  weeks  of  life 
twenty  hours  per  day ;  at  the  end  of  a  year,  for  from 
twelve  to  fifteen  hours  ;  between  the  second  and  third  year, 
eleven  to  fourteen  hours ;  from  the  fifth  to  the  seventh 
year,  ten  to  eleven  hours ;  in  the  seventh  year,  ten  hours, 
and  in  the  twelfth  year,  nine  hours.  These  figures  vary, 
of  course,  in  different  individuals.  The  sucking  infant 
sleeps,  as  a  rule,  several  hours  after  nursing. 

Temperature. — The  tem])erature  of  the  newborn  is  from 
37.8°  to38.5°  C.  [101 .6°-102.2°  F.].  From  the  second  day 
on  the  temperature  is  that  of  an  adult,  37.0°  to  37.5°  C. 
[98.6°-100"  F.].  It  rises  during  crying  spells  and  when^ 
the  child  is  given  nourishment,  and  sinks  during  sleep 
and  when  bathed  (about  0.1°-0.5°  C.  [.l°-.9°  F.]). 


INCREASE  IN   WEIGHT  35 

Heat  production  and  heat  dissemination  are  greater  in 
a  child  tlian  in  an  adult.  According  to  Vierordt  the 
ratio  is  as  follows  : 

1  kg.  of  body  weight  of  the  newborn 130,000  calories. 

1  kg.  of  body  weiglit  of  one  and  a  half  yeai-s   ....    91,000        " 
1  kg.  of  body  weight  of  an  adult 39,000        " 

The  greater  degree  of  heat  dissemination  depends  upon 
the  relatively  larger  amount  of  surface,  the  more  rapid 
circulation,  and  the  increased  respiration  rate. 

Excretion  of  Urine. — The  urine  is  already  excreted  in 
ntero.  It  is  scarce  during  the  first  two  days  of  life,  and 
then  increa.ses  in  proportion  to  the  amount  of  fluid  in- 
gested. When  100  gm.  of  milk  are  taken,  the  urinary 
output  amounts  to  60  to  70  gm.  (Bendix).  The  daily 
amount  of  urine  secreted  is  as  follows :  first  day,  17  gm.; 
second  to  third  day,  40  to  50  gm. ;  eighth  day,  250  gm. ;  six 
months,  500  to  600  gm. ;  after  which  it  rises  to  one  liter 
(luring  the  years  of  puberty.  The  urine  during  the  first 
days  of  life  contains  albumin,  tubular  casts,  and  crystals 
of  uric  acid.  (For  examination  of  urine,  see  Renal 
Diseases.) 

Special  Senses. —  Vision. — Newborn  infants  are  sen- 
sitive to  light  and  cannot  bear  diffuse  daylight  until  after 
the  second  or  third  week.  Light  and  dark  are  distin- 
guished after  a  few  days.  Objects  can  be  focussed  after 
four  or  five  weeks.  Primarily  the  eye  is  myopic  becau.se 
of  greater  curvature  of  the  cornea.  [Some  authors  main- 
tain that  the  eye  is  hypermetropic  during  the  first  days  of 
life. — Ed.] 

Hearing. — Deafness  exists  during  the  first  twenty-four 
to  thirty-six  hours,  because  of  swelling  of  the  mucous  mem- 
brane of  the  middle  ear.  In  the  course  of  a  few  weeks 
the  infant  hears  noises  ;  during  the  whole  first  year  a  dis- 
agreeable sensation  is  produced  by  shrill  tones  and  noi.ses. 
The  other  special  sen.ses  are  developed,  with  the  exception 
of  the  sense  of  space,  Avhich  becomes  functional  with  the 
enlarged  experiences  of  later  childhood. 

Movements. — The  first  movements  are  reflex  and  auto- 


36  PHYSIOLOGIC  PECULIARITIES 

PLATE  3 

•  Fig.  1.  The  Upper  and  Lower  Jaws  of  a  Child  during  the  Second 
Dentition. — The  lower  iucisor  teeth  liave  erupted  abnormallj-  previous  to 
the  mohir  teeth.     (The  upper  jaw  has  been  divided  in  the  median  line.) 

Fig.  2.  Complete  Set  of  Milk  Teeth.— Sliowing  the  position  of  the 
permanent  tooth  crowns  above  and  beliind  the  adventitious  roots.  (From 
a  preparation  in  the  Anatomic  Institute  of  Munich.) 

matic.  The  first  voluntary  movement  i.s  lifting  of  the  head ; 
the  ability  to  grasp  voluntarily  does  not  occur  until  the 
second  or  third  month  ;  sitting,  the  sixth  month  ;  standing 
and  walking,  after  one  year. 

Dentition. — The  temporary  teeth  erupt  in  the  following 
order : 

1.  The  lower  central  incisors  in  from  five  to  eight 
months. 

2.  The  upper  central  incisors  in  from  six  to  nine 
months  (four  weeks  later). 

3.  The  upper  lateral  incisors  soon  thereafter. 

4.  The  lower  lateral  incisors  at  the  end  of  the  first 
year  of  life. 

5.  The  first  molars  soon  thereafter. 

6.  The  canine  teeth  about  the  middle  of  the  second 
year  of  life. 

7.  The  outer  molars  from  the  twenty-second  to  the 
thirtieth  month. 

There  is  considerable  variation  in  different  individuals 
as  to  the  order  and  period  of  eruption.  The  latter  is 
delayed  in  rachitis,  syphilis,  and  tuberculosis. 

The  .second  dentition  begin.s  about  the  sixth  year, 
and  the  various  teeth  erupt  as  follows  : 

1.  The  first  molars  in  the  fifth  or  sixth  year. 

2.  The  middle  incisors  in  the  sixth  to  ninth  year. 

3.  The  lateral  incisors  in  the  seventh  to  tenth  year. 

4.  The  first  bicu.spids  in  the  ninth  to  thirteenth  year. 

5.  The  canine  teeth  in  the  ninth  to  fourteenth  year. 

6.  The  second  bicuspids  in  the  tenth  to  fourteenth 
year. 

7.  The  second  molars  in  the  tenth  to  fourteenth  year. 

8.  The  third  molars  in  the  sixteenth  to  fortieth  year. 
The  first  dentition  proceeds  either  without  symptoms 


Fiff.l. 


Fuj.. 


DIGESTION.  37 

or  it  shows  certain  phenomena.  Thus  pains  may  occur 
before  or  during  the  eruption.  There  may  also  be  swell- 
ing and  reddening  of  the  gums,  salivation,  flushed  cheeks, 
and  styes  [?].  Symptoms  may  occur  because  of  an  in- 
creased excitability  of  the  nervous  system  :  restlessness, 
crying,  convulsions,  an  irritable  cough,  frequency  of  urina- 
tion, diarrhea,  vomiting,  eruption  of  the  so-called  "  tooth- 
rash  "  (see  Strophulus  infantum).  [It  is  very  doubtful 
whetiier  all  these  symptoms  are  produced  by  dentition. 
We  would  grant  that  local  discomfort  and  general  rest- 
lessness might  occur  at  this  time.  It  does  not  seem  in 
accord  with  modern  pathologic  conceptions  to  assume 
that  convulsions,  cough,  vomiting,  diarrhea,  etc.,  can  re- 
sult from  teething.  These — for  the  most  part  acute  con- 
ditions— disappear  very  shortly  under  appropriate  treat- 
ment, though  the  process  of  dentition  still  continues. — 
Ed.] 

The  resorption  of  the  milk  teeth  begins  with  the  dis- 
appearance of  the  last  deciduous  teeth  by  the  crowding 
onward  of  the  permanent  teeth.  The  latter  lie  almost 
completely  developed  back  of  and  underneath  the  milk 
teeth,  and  on  account  of  insufficient  space  are  frequently 
pushed  upward  or  downward.  Thus  the  particularly  large 
canine  tooth  is  displaced  as  far  as  the  infra-orbital  foramen. 

DIGESTION 

The  oral  a])paratus  of  the  suckling  functionates  only 
as  a  pump;  chewing  and  salivation  are  impossible  on  ac- 
count of  the  weak  muscles  of  mastication,  the  lack  of 
teeth,  and  the  insufficiency  of  saliva.  The  oral  cavity  of 
a  newborn  child  is  dark  red  in  color  and  dry.  Only 
traces  of  the  diastase  ferment  are  present,  but  appear  in 
appreciable  quantities  after  the  second  month.  The  in- 
fant can,  therefore,  ingest  nothing  but  liquids. 

Pepsin,  hydrochloric  acid,  and  rennin  are  secreted  in 
the  stomach.  The  casein  of  the  milk  is  precipitated,  and 
the  free  hydrochloric  acid  becomes  united  with  the  casein, 
which   is   partially  dissolved.      From   the  sugar  of  milk 


38  PHYSIOLOGIC  PECULIARITIES 

lactic  acid  is  formed.  Aside  from  the  above  action  hydro- 
chloric acid  has  a  bactericidal  one  also.  The  nntriment 
leaves  the  stomach  of  artificially  fed  children  in  from 
three  to  four  hours,  while  in  breast-fed  children  it  passes 
out  in  from  one  and  a  half  to  two  hours,  that  organ  serv- 
ing only  as  a  collecting  and  preparatory  station.  The 
fate  of  the  food  in  the  intestines  through  which  it  })asses 
in  six  to  eight  hours  is  as  follows  :  The  jiancreatic  juice 
and  the  bile  alter  its  reaction  and  color ;  the  albumin 
digestion  continues ;  the  casein  becomes  peptonized ;  the 
fats  are  split  up,  saponified,  and  absorbed ;  the  sugars 
and  dissolved  salts  are  absorbed,  as  are  also  the  albumins. 

In  the  large  intestine  the  water  and  the  remaining 
unabsorbed  dissolved  substances  are  absorbed.  The  bac- 
teria, which  are  normally  present  in  the  large  and  small 
intestines  (Bacillus  acidophilus — Moro;  B.  coli  and  B. 
lactis  aerogenes — Escherich),  are  important  for  the  pur- 
pose of  proteid  digestion,  fermentation  of  milk-sugar, 
protection  against  invading  pathogenic  micro-organisms, 
and  to  excite  peristalsis.  The  undigested  portions  of  the 
food  and  the  residue  of  the  digestive  juices  pass  out  as 
feces  and  eventually  form  jiathogenic  pnxlucts.  The 
stools  of  the  first  few  days — the  meconium — are  blackish 
green  in  color,  odorless,  acid,  and  composed  mainly  of  the 
digestive  agents  excreted  by  the  intestines.  Microscop- 
ically they  contain  cylindric  epithelium,  mucoid  bodies, 
fat  globules,  cholesterin,  and  minute  hairs. 

Next  follow  transitory  stools,  which  partake  of  the 
color  of  meconium  and  milk  stools.  The  normal  breast 
stool  is  golden  yellow  in  color,  of  the  consistency  of  soft 
paste,  frequently  somewhat  nodular,  almost  odorless,  and 
slightly  acid  in  reaction.  The  normal  stool  of  babies  fed 
on  cows'  milk  is  paler  and  of  a  lighter  yellow  color,  it 
possesses  the  consistency  of  paste,  and  is  formed.  As  a 
rule  it  has  an  acrid  odor,  slightly  acid  or  alkaline  .in 
reaction,  and  is  discharged  in  larger  quantities.  After 
the  ingestion  of  a  meal,  especially  cereal  foo<ls,  the  stools 
become  brownish  in  color.  The  constituents  of  the  stools 
are   85  per  cent,  water,  casein,  fatty  acid  salts,  mucus, 


NATURAL  FEEDING  39 

sodium  chlorid,  cholesterin,  and  bilirubin.  A  microscopic 
examination  shows  micro-organisms,  fat,  epithelial  cells, 
and  vegetable  debris. 


NOURISHMENT 
NATURAL  FEEDING 

The  only  form  of  nutriment  which  is  fully  adequate 
for  the  nourishment  of  a  child's  body  is  that  derived  from 
its  mother's  milk.  Such  nourishment  should  be  attempted 
in  every  case,  excej)ting  when  the  mother  is  suffering 
from  pronounced  tuberculosis,  for  it  is  also  of  advantage 
to  her  (favors  prompt  involution  of  the  genitals,  protec- 
tion against  conception,  and  has  a  tendency  to  improve 
the  nourishment  of  her  own  body).  When  there  is  really 
insufficient  milk,  artificial  feeding  should  be  accompanied 
by  at  least  several  attempts  to  feed  from  the  breast,  as 
tills  mixed  feeding  is  of  greater  value  to  the  child  than 
a  purely  artificial  diet. 

Constituents  of  Human  Milk. — Water,  albuminoids,  fiit, 
sugar,  and  salts.  Aside  from  these  elements,  human  milk 
contains  also  unknown  antitoxins  and  immune  bodies,  as 
well  as  a  number  of  ferments  (Escherich,  Moro),  which 
are  of  importance  for  internal  metabolism. 

After  a  period  of  nursing  the  following  characteristics 
are  noted  : 

Colostrum  is  the  name  given  to  the  milk  during  the  first 
eight  days.  It  is  richer  in  albumin  and  salts,  but  poorer 
in  fat,  and  contains  larger  amcmnts  of  the  so-called  colos- 
trinn  bodies — ^.  c,  fatty  degenerated  mammary  epithe- 
lium (see  Fig.  8,  h). 

The  milk  of  the  first  tioo  months  shows  an  increase  of 
albumin,  salts,  and  colostrum  l)odies,  and  gradually 
comes  to  resemble  the  permanent  milk. 

Permanent  milk  remains  nearly  constant  as  to  its  con- 
stituents during  the  whole  period  of  lactation ;  it  no 
longer  contains  colostrum  bodies,  and  the  fat  globules 


40 


NOUEISHMENT 


Fig.  8. — (a)  Maternal  milk.     Tlic  fat  globules  arc  of  varying  size,  but 
show,  as  a  rule,  equal  subdivision  ;  no  colostrum  bodies. 


:6t 


'-"01 


(6)  Colostrum.  The  fat  globules  are  unequally  divided,  agglutinated 
in  certain  areas,  and  show  marked  diflferences  in  size  (large  fat  vacuoles) ; 
the  colostrum  bodies  may  be  recognized  as  pale  gray  areas  partially  cov- 
ered with  fat. 


are   of  varying   size,    but   nearly  similar   in   form  (see 
Fig.  8,  a). 


NATURAL  FEEDING  41 

Comparison  of  Vay^ious  Milks  {Heubner  and  othci's) 
100  gm.  milk  contain  in  grams  : 


Other  nitro- 

gen-contain- 

Source. 

Albumin. 

Fat. 

Sugar. 

Salts. 

ing  and 

unknown 

bodies. 

Human 

0.9 

3.52 

6.75 

0.197 

0.6 

Cow 

3.0 

3.55 

4.51 

0.7 

0.3 

Goat 

2.8 

3.40 

3.80 

0.95 

Mare 

1.9 

1.00 

6.33 

0.45 

0.5 

1.63 

0.93 

5.60 

036 

The  portion  of  milk  which  is  first  drawn  is  more 
watery  than  that  which  is  obtained  at  the  end  of  a 
nursing. 

The  number  of  meals  daily  during  the  first  few  weeks 
should  be  seven  ;  later,  six  or  five. 

The  size  of  the  individual  meals,  according  to  Feer, 
are : 


Weeks. 

2. 

4. 

8 

■ 

12. 

16. 

20. 

Average  amounts  .... 
Maximal  amounts  .... 
Capacity,     according      to 

90 
140 

110 
160 

90 

140 
215 

100 

150 
240 

110 

160 
260 

125 

170 
270 

140 

The  difference  between  the  capacity  and  the  amount  of 
milk  ingested  is  due  to  the  fact  that  the  milk  pa.sses  into 
the  duodenum  during  nursing. 

During  the  first  two  days  only  a  very  small  amount  is 
drunk.  The  amount  of  milk  taken  daily  increases  in  the 
first  few  weeks  from  10  gm.  to  400  to  500  gm.,  and  then 
continues  to  increase. 

The  amounts  drunk  by  a  breast-fed  child,  according  to 
Bendix  and  others,  are  : 


42  NOURISHMENT 

At  the  end  of    1st  week  of  life 250  grams. 

At  the  end  of    2d  "  " 500  " 

At  the  end  of    3d  "  " 550  " 

At  the  end  of    4th  "  " 600  " 

At  the  end  of    8th  "  " 800  " 

At  the  end  of  12th  "  " 850  " 

At  the  end  of  16th  "  " 860  " 

At  the  end  of  20th  "  " 930  " 

At  the  end  of  24th  "  " 1000  " 

The  amount  of  food  required  by  a  nursling,  as  has  been 
recently  determined,  depends  upon  the  energy  which  such 
food  can  produce  (Heubner).  The  number  of  calories, 
per  1  kg.  of  body  weight,  which  are  obtained  from  the 
food  are  indicated  as  the  "  energy-quotient "  (Heubner). 
This  energy-quotient  during  the  first  half  year  equals 
100. 

According  to  Rubner  the  number  of  calones  produced 
by  various  forms  of  nourishment  are  as  follows  : 

In  1  liter. 
Human  milk  (depending  upon  the 

amount  of  fat  present) from  614-724  calories. 

Cows'  milk from  690-724  " 

Two-thirds  milk  ( according  to  Heubner)  from  480-724  " 

One-third  milk  with  sugar       from  340-724  " 

Buttermilk  (according  to  de  Jager)  .    .  from  698-724  " 

Liebig  extract  (according  to  Keller)    .  from  808-724  «« 

A llenbury's  milk  mixture       from  546-724  " 

Asses'  milk  (from  Dresden) from  502-724  " 

Flour  soup  (5  percent. — from 

Rudemann's  meal ) from  195-724  " 

The  following  example  shows  the  manner  of  figuring 
out  the  amount  of  food  required : 

A  child  weighing  7  kg.  requires  700  calories ;  the 
amount  of  human  milk  required  (see  table)  =^^{{^  gm. 
(1.07  liters).  The  amount  of  cows*  milk  required  =  |^ 
gm.  (1. 01  liters). 

For  practical  purposes  it  .should  be  remembered  that 
a  healthy  child  must  receive  daily  during  the  first  three 
months  about  one-sixth,  and  during  the  second  and  third 
months  about  one-seventh,  of  its  body  weight  of  human 
milk  (Heubner). 

In  other  words,  the  amount   of  food   ingested   daily 


NATURAL  FEEDING  43 

during  the  first  week  of  life  should  be  10  per  cent,  of  the 
body  weight ;  in  the  second  to  fourth  week,  16  per  cent.; 
in  the  second  month,  17  per  cent.  After  this  period  the 
percentage  is  about  1  per  cent,  less  every  month  (Oppen- 
heimer). 

Breast  Feeding. — The  breasts  should  be  prepared  during 
the  pregnancy  by  washing  and  massage  of  the  nipples. 
The  child  is  applied  to  the  breast  for  the  first  time  on  the 
first  or  second  day.  In  case  it  is  hungry  and  the  milk 
has  not  yet  appeared  a  teaspoonful  of  camomile  tea  may 
be  given  [warm  water  answers  the  same  purpose]. 
If  the  nipples  are  hard  to  grasp  a  nipple-shield  or  breast- 
pump  may  be  employed.  At  the  beginning  the  child 
should  be  put  to  the  breast  every  two  hours,  later,  every 
three  hours.  The  child  should  become  accustomed  to 
feed  at  regular  intervals. 

It  is  best  to  confine  the  nursing  to  one  breast  until 
satisfied.  The  rest  following  nursing  should  continue 
for  from  four  to  five  hours.  The  beginning  of  menstru- 
ation, or  slight  disturbances  in  the  health  of  the  child, 
should  not  interrupt  the  nursing.  The  mother  should  be 
given  no  special  diet,  but  should  continue  her  accustomed 
food  as  long  as  the  appetite  remains  good.  She  may 
take  as  much  milk  as  possible,  but  without  compulsion. 
Alcohol  must  be  avoided,  her  occupation  regulated,  and 
she  must  take  regular  exercise  in  the  open  air. 

The  child  should  not  be  weaned  until  the  sixth  month 
and,  if  possible,  not  during  the  hot  season.  It  should 
be  pre])ared  gradually  throughout  the  course  of  weeks  by 
the  administration  of  artificial  meals  (milk  mixtures, 
broths,  and,  under  certain  circumstances,  bouillon). 

Indications  for  Weaning. — Pregnancy,  acute  febrile  dis- 
eases of  the  mother,  insufficient  milk  (the  child's  weight 
failing  to  increase  and  the  occurrence  of  constipation), 
unsuitable  milk  (the  presence  of  colostrum  bodies  in  the 
permanent  milk,  fat  corjiusclcs,  bacteria),  and  chronic 
dyspepsia  of  the  infant.  When  there  is  a  relative  in- 
sufficiency of  milk  the  mixed  feeding  should  be  continued 
as  long  as  possible. 


44  NOURISHMENT 

When  the  mother  is  unable  to  nurse  the  diikl,  artificial 
feeding  should  be  resorted  to,  and  not  until  this  fails  should 
a  wet-nurse  be  obtaiiied.  The  requirements  of  a  good 
wet-nurse  are:  Good  health  ;  it  is  especially  important  that 
she  should  be  free  from  tuberculosis  and  syphilis,  of  other 
acute  or  chronic  diseases,  and  be  capable  of  producing  a 
large  amount  of  good  milk.  Her  condition  may  also  be 
judged  by  the  health  and  body  weight  of  her  own  child, 
and  by  a  careful  observation  of  the  increase  in  weight  and 
the  amount  of  milk  taken  by  the  child  to  be  nursed.  A 
chemic  examination  of  the  milk  is  of  value.  Pressure 
upon  the  glands  should  cause  the  milk  to  appear  in  several 
streams.  As  regards  the  quality  of  milk,  the  age  of  the 
gestation  period  is  of  little  significance,  yet  it  is  advisable 
for  safety's  sake  not  to  accept  a  wet-nurse  previous  to  six 
weeks  after  confinement,  and  for  social  reasons,  not  after 
three  months.  The  offspring  of  the  wet-nurse  should  not 
be  brought  into  the  house.  [There  are  several  reasons 
why  a  wet-nurse  should  be  jiermitted  to  have  her  own 
baby  with  her: 

(1)  The  moral  question  of  consigning  her  own  baby  to 
an  institution,  probably  to  its  death.  To  this  there  can 
be  only  one  answer. 

(2)  The  wet-nurse's  baby  frequently  stimulates  the 
breasts  and  keeps  up  the  supply  of  milk. 

(3)  If  she  does  not  care  for  her  own  baby,  it  is  doubt- 
ful if  she  ought  to  be  trusted  with  another's  baby. 

(4)  She  is  more  contented  and  in  a  better  mental  state, 
in  consequence  her  milk  is  mf)re  likely  to  be  normal. 
She  will  have  no  valid  excuse  to  make  visits  or  absent 
herself  from  her  charge.  For  this  reason  she  is  at 
home  when  she  is  needed,  and  her  food  and  morals  are 
under  control. — Ed.] 

ARTIFICIAL   FEEDING 

Artificial  feeding,  even  under  the  most  favorable  cir- 
cumstances, is  not  an  absolute  satisfactory  substitute  for 
the  mother's  breast.     For  this  purpose  cows'  milk  is  the 


FREEING   THE  MILK  OF  FOREIGN  MATERIAL     45 

best,  partly  because  the  milk  of  other  animals  is  too  ex- 
pensive and  partly  because  of  a  difference  in  constituency. 

Cows'  milk  differs  from  human  milk  in  the  following 
respects  :  The  presence  of  dirt  and  bacteria ;  it  contains 
three  times  the  quantity  of  albumin ;  by  the  chemic  union 
of  the  albuminoid  bodies ;  by  the  comparatively  larger 
amounts  of  dissolved  albumin  (relation  of  casein  to  albu- 
min in  cows'  milk  =  10  : 1,  in  human  milk  =  10  :  12); 
larger  amounts  of  salts  and  less  sugar ;  larger  curds  of 
casein  ;  greater  acidity,  on  account  of  which  less  hydro- 
chloric acid  is  set  free  in  cows'  milk  to  prevent  fermen- 
tation. The  casein  of  cows'  milk  is  not  more  indigestible 
than  that  of  human  milk  (Heubner,  Bendix). 

In  preparing  an  infant's  fo(xl  an  attempt  is  made  to 
compensate  for  these  differences  by  obtaining  milk,  if 
possible,  which  is  clean  and  free  from  bacteria,  and  con- 
verting it  both  chemically  and  physically  to  correspond  to 
human  milk,  and  thus  obtain  perfect  equalization. 

FREEING  THE  MILK  OF  FOREIGN  MATERIAL 
AND  BACTERIA 

To  obtain  clean  milk  :  Judicious  feeding  and  care  of 
the  animals  ;  exclusion  of  diseased  cows,  and  cows  tested 
with  tuberculin  ;  mixed  milk  is  better  than  the  milk  from 
one  cow,  because  of  the  greater  dilution  of  the  injurious 
substance's.  The  cows  should  be  milked  under  clean  and 
sanitary  circumstances.  The  milk-slime  should  be  separated 
by  means  of  a  centrifuge  or  an  aseptic  filter.  The  milk 
is  to  be  rapidly  cooled  and  kept  cool  until  delivered  ;  cen- 
trally located  model  milk  establishments  for  the  distribu- 
tion of  milk.  When  it  is  impossible  to  obtain  raw  milk 
free  of  bacteria,  the  latter  should  be  destroyed  either  by 
simply  boiling  in  covered  vessels,  set  aside  to  cool  rapidly 
and  kept  cool,  or  by  steam  sterilization  at  home  in  a 
Soxhlet  apparatus  (sterilization  of  from  ten  to  fifteen  min- 
utes insures  a  durability  of  from  two  to  three  days). 
Another  method  is  to  pasteurize  the  milk,  that  is,  heating 
it  to  68°  to  70°  C.  [154.4-158°  F.]  in  an  apparatus  like 


46  NOURISHMENT 

that  of  Oppenheiraer,  Kobrack,  or  by  the  agitation 
method  more  recently  described  by  Gerber. 

Aside  from  the  ease  of  sterilization,  the  Soxhlet  method 
has  the  additional  advantage  of  preparing  a  whole  day's 
supply  in  individual  bottles  securely  protected  and  ready 
for  use. 

Results  of  Sterilization. — Sterilization  gives  the  milk  an 
unpleasant  taste  and  disagreeable  odor,  and  alters  its  com- 
position in  all  respects,  destroying  the  ferments  and 
immune  bodies.  It  creates  a  monotonous  diet ;  in  arti- 
ficially fed  infants  the  tendency  to  anemia  and  distur- 
bances of  metabolism  so  frequently  observed  may  be 
traced  to  it. 

EQUALIZING  THE  CHEMICOPHYSICAL  DIFFERENCES 
ACCORDING  TO  VARIOUS  METHODS 

Diminishing  the  albumin  content  by  dilution  or  partial 
precipitation.  The  casein  of  cows'  milk  is  probably  not 
less  digestible  than  that  of  human  milk,  but  on  account 
of  the  increase  of  albumin,  the  digestion  of  the  albuminoids 
is  more  likely  to  be  interfered  with  in  sucking  infants 
than  favored  (Heubner). 

The  loss  of  fat  and  sugar  in  the  dilution  is  compensated 
for  by  the  addition  of  either  sugar  of  milk  or  cream  (Bie- 
dert),  or  of  sugar  of  milk  alone  (Heubner),  or  of  nutritive 
sugar  [Nahrzucker]  (Soxhlet),  until  the  mixture  possesses 
an  equal  percentage  of  ingredients,  or  (Biedert)  an  energy 
potential  equal  to  that  of  human  milk  (Heubner). 

For  practical  purposes  we  proceed  as  follows :  As  a 
diluting  fluid  a  thin  decoction  of  oatmeal  or  barley  is 
employed,  to  each  100  grams  of  which  1  coffeespoonful 
of  sugar  of  milk  or  2  coffeespoonfuls  of  nutritive  sugar 
(or  Liebig's  powdered  extract)  are  added.  Begin  with 
one-third  milk  and  two-thirds  of  this  solution,  and  gradu- 
ally increase  to  one-half  of  each.  In  two  or  three  months 
a  two-thirds  mixture  is  employed.  In  from  six  to  eight 
months  only  milk  is  employed.  The  increase  in  concen- 
tration of  the  food  depends  upon  individual  conditions. 

Preparation  of  Heubner' s  two-tkirds  mixture  (two-thirds 


EQUALIZING   CHEMICOPHYSICAL  DIFFERENCES    47 

milk,  one-third  of  12  per  cent,  solution  of  sugar  of  milk) : 
1000  parts  contain  18  of  albumin,  24  of  fat,  70  of  sugar, 
47  of  ash  =  640  calories.  This  represents  approximately 
1  liter  of  human  milk.  There  is  used  of  this  mixture  at 
first  I  liter,  then  1  liter,  and  finally  1 200  gm.  in  twenty- 
four  hours. 

These  figures  are  only  approximately  correct,  it  being 
impossible  to  present  a  scheme  of  feeding  which  would 
serve  in  all  cases. 

The  Administration  of  Milk. — At  the  beginning  it  should 
be  given  after  two-  and  then  after  three-hour  intervals. 
The  number  and  size  of  each  feeding  are  regulated  as 
in  the  case  of  breast-fed  children ;  the  amount  is,  as  a 
rule,  somewhat  larger. 

Chief  Danger  :  Overfeeding. — The  rubber  nipple  must 
be  daily  boiled  and  preserved  in  a  solution  of  boric  acid 
and  dried.  The  milk-bottles  must  possess  smooth  walls. 
The  temperature  is  to  be  personally  observed. 

Feeding  with  gruel  after  three  or  four  months  once 
daily.  In  the  course  of  time  fruit  juice  maybe  given. 
Other  highly  recommended  preparations  of  milk  are 
mainly  used  when  the  above  mixtures  of  milk  and  sugar 
cannot  be  digested.  The  most  important  of  these  prep- 
arations are :  ^ 

Group  I. — Milk  mixtures  containing  a  diminished 
amount  of  albumin  and  an  increased  amount  of  fat. 

Biedert's  cream  mixture.  Receipt:  Diminishing  amount 
of  albumin  by  diluting  with  water ;  gradual  increase  of 
same  by  addition  of  milk  and  substituting  fat  and  sugar 
by  cream  and  sugar  of  milk. 

Natural  cream  mixture  No.  I.  consists  of  \  liter  of 
cream,  |  liter  of  water,  and  18  gm.  of  sugar  of  milk.  No. 
II.  consists  of  tiie  same  and  y'g  liter  of  milk ;  the  addi- 
tion of  milk  increases  then  until  f  liter  is  reached,  after 
which  water  and  sugar  of  milk  are  decreased.  The 
preparation  of  cream  "Ramogen"  is  more  convenient;  it 
can  be  regulated  by  the  addition  of  water  and  increasing 
the  amount  of  milk. 

^  As  grouped  by  Bendix. 


48  NOURISHMENT 

Drenckhan's  milk. 

Gartner's  milk. 

Lehmann's  vegetable  milk  (formula  for  cream  mixtures, 
combined  with  vegetable  albumin  and  fat,  employed  as 
an  addition  to  milk). 

Condensed  (Swiss)  milk,  with  high  percentage  of  cane- 
sugar. 

Monti's  Vienna  infant's  milk  (milkthinnedwith  whey). 

Group  II. — Diluted  milk  mixtures  containing  an 
increased  amount  of  fat,  and  in  which  the  albuminoids 
are  predigested  and  held  more  or  less  in  solution. 

Backhaus'  milk.  No.  I. :  Addition  of  cream  from 
which  a  portion  of  the  casein  has  been  dissolved  by  tryp- 
sin.    No.  II.  :  Milk-fat.     No.  III.  :  Pure  milk. 

Voltmer's  mother's  milk  (conversion  of  the  casein  of 
cows'  milk  into  peptone  by  the  addition  of  the  pancreatic 
ferment ;  otherwise  its  constituents  are  analogous  to  that 
of  human  milk). 

LoeflBund's  peptonized  milk. 

von  Dungern's  milk  rennet  (addition  of  a  knife-point- 
ful of  "pegnin"  to  200  gm.  undiluted  milk). 

Group  III. — Diminution  of  the  albumin  content  by 
dilution,  increase  of  fat,  substitution  for  the  deficit  of 
albumin  by  a  soluble  albuminate  or  peptone. 

Rieth's  albumose  milk  (substitution  of  the  casein  by  a 
non-coagulable  form  of  albumose,  which  is  d(U'ivcd  fi'om 
egg-albumin  by  means  of  heat).  Addition  of  cream  and 
sugar.     Hartmann's  somatose  milk  is  similar  in  character. 

Hempel-Lehmann's  milk  (dilution  of  cows'  milk  until 
it  contains  75  per  cent,  of  casein.  The  addition  of  a 
yelk — phosphorus  and  iron — and  the  white  of  an  e^g, 
enriched  with  fat  and  sugar  of  milk). 

Group  IV. — Mixtures  poor  in  fat,  but  rich  in  sugar 
(especially  malt  sugar). 

Liebig's  soup  (conversion  of  wheat  flour  into  maltose); 
a  more  recent  form  of  this  preparation  is  Keller's  malt 
soup  (50  gm.  of  wheat  flour  and  650  water,  1 00  gm.  of  Loef- 
flund's  malt-soup  extract  and  350  milk);  both  mixtures 
being  cooked  together. 


EQUALIZING   CHEMICOPHYSICAL  DIFFERENCES    49 

Allenbury's  infant's  food  No.  III.  (malted  food). 

Liebe's  neutral  food  (Dresden). 

Soxhlet's  nutritive  sugar  (a  wheat  flour  converted  into 
dextrin  and  maltose),  to  which  has  been  added  a  certain 
amount  of  acids  as  well  as  digestive  salts  and  table  salt. 

Brunnengriiber's  (Rostock)  powdered  malt. 

The  useful  forms  of  flour  for  children  are  classified  as 
follows  :  1 

Simple  prepared  flour,  over  5  per  cent,  fat :  Knorr's 
and  Weibezahn's  prepared  oatmeal. 

Infant  foods  (prej)ared  from  milk  and  diastasized  flour 
or  malt)  containing  a  high  percentage  of  fat :  Faust  and 
Schuster  (4.5  per  cent,  fat),  Nestle  (5.1),  Rademann  (6), 
and  Muffler  (6.4). 

Infant  foods  containing  a  low  percentage  of  fat :  Soxh- 
let's Liebigsoup  ;  Mellin  (0.3  per  cent.),  Kufeke  (0.8), 
Opel's  nutritive  zwieback  (1.3),  Ridge  (1.3),  Neave  (1.7). 

Foods  containing  large  amounts  of  easily  soluble 
starches  are  :  Mellin,  Theinhard,  Nestle  ;  containing  large 
amounts  of  starches  soluble  with  difficnlty  :  Neave,  Ridge, 
Weibezahn,  Rademann,  and  Kufeke. 

In  two  and  a  half  years  the  following  articles  of  diet 
may  be  gradually  given  :  Veal  broth  and  also  well-cooked 
veal,  apple  sauce,  various  fruit  juices,  biscuits,  pur^e  of 
carrots,  cauliflower,  spinach,  fresh  strawberries,  finely 
sliced  apples.  The  chief  form  of  nutrition  from  the 
second  year  on  must  still  be  milk,  supplemented  by  a 
mixed  diet  of  meat,  vegetables,  potato  broth,  fruit,  zwie- 
back, butter  rolls,  easily  digested  farinaceous  foods,  etc. 
Regular  meals  of  milk  should  be  continued  as  long  as 
possible  (the  milk-bottle  must  not  be  withdrawn  too 
soon). 

EXAMINATION   AND  HISTORY 

The  examination  of  children  follows  the  same  rules  as 
in  the  case  of  adults.     As  in  each  individual  case  differ- 
ent charatteristics  are  met  with,  it  is  advisable  to  follow 
a  certain  routine  in  order  to  avoid  errors. 
'  Author's  division. 


50  EXAMINATION  AND  HISTORY 


ANAMNESIS 

The  following  is  in  a  general  way  a  reproduction  of  the 
plan  outlined  for  the  Children's  Hospital  of  Munich  : 

The  number  of  the  child?  Diseases  and  deaths  of 
parents,  brothers,  and  sisters?  Previous  premature 
births?  Form  of  feeding  to  date:  Breast?  cows'  milk? 
broth  ?  beer?  meat  diet  ?  Sleep.  Digestion.  Domestic 
conditions,  sanitary  state  of  the  home,  care  and  attention 
of  the  child.  Hardening  ?  Source  of  the  milk,  handling, 
and  method  of  administration  (long  tube,  nipple,  or 
graduated  bottle). 

Previous  diseases  of  the  child,  especially  disturbances  of 
digestion,  convulsions,  diseases  of  the  lungs,  eru[)tions, 
enlargement  of  the  glands,  ocular  and  aural  discharges, 
infectious  diseases,  course  and  treatment  of  such  dis- 
eases (exact  data). 

Present  Illness. — Beginning,  course,  and  treatment  up 
to  date  (always  give  data). 

In  case  of  special  diseases  greater  details  are  required. 
Thus  one  must  consider  : 

In  Nervous  Diseases. — The  variety  and  duration  of 
labor  when  child  was  born  ;  past  trauma  ?  Whether 
there  was  any  nervous  disease,  suicide,  alcoholism,  etc., 
amongst  the  relatives.  Physical  and  mental  development 
and  character  of  the  child  ;  the  form  and  duration  of  cold- 
water  treatments,  etc.,  if  such  were  undertaken  at  any 
time  in  the  past.     The  presence  of  adenoids. 

In  Rachitk. — Form  of  nourishment,  as  above.  The 
course  of  dentition.  Learning  to  stand  and  walk. 
Sweats  in  occiput ;  outcry  upon  being  lifted.  Restless- 
ness?    Diarrhea?     Age  "of  parents  ;  hereditary  syphilis. 

In  Ilei-editary  Syphilis. — Former  premature  births, 
stillbirths,  period  and  nature  of  same.  Healthy  chil- 
dren during  intervals?  From  one  or  more  fathers? 
Possible  syphilis  in  parents.  Coneerninrf  the  child  itself: 
Full-time  baby?     Snuffles?     Eruptions'? 

In  DiseaJies  of  Metaholism. — Character  of  the  infant's 
feeding — if  milk,  how  long  sterilized  and  until  what  age 


PROPER  METHOD  OF  EXAMINING  A    CHILD      51 

was  it  administered?  (Anemia,  Barlow's  disease.)  Hard- 
ening with  cold  water?  (Anemia.)  In  dysthyroidal 
conditions,  myxedema,  infantilif^m,  cretinism,  etc.,  inquire 
into  the  existence  of  the  following  conditions  in  ancestors, 
brothers,  or  sisters :  Goiter,  idiocy,  obesity,  gout,  gall- 
stones, excessive  genital  hemorrhages,  sensitiveness  to 
cold,  cold  hands  and  feet. 

In  Diseases  of  the  Respiratory  Tract. — Colds,  exposure 
to  wet,  former  diseases  of  respiratory  organs,  hardening 
procedures,  measles,  whooping-cough  as  an  excitant  of 
latent  tuberculosis.  Possibility  of  aspirated  foreign 
bodies  ?     Chronic  pulmonary  diseases  in  relatives. 

In  Diseases  of  Digestive  Trad. — In  sucklings  determine 
accurately  the  former  modes  of  feeding — broths,  milk — 
source,  especially  in  bottle-fed  children,  and  preparation 
and  method  of  administration  of  the  milk.  Infant's 
milk?  Feeding  of  the  cows.  Mixed  milk,  or  milk 
from  one  cow,  possibly  from  one  infected  with  bovine 
tuberculosis.  At  what  time  delivered  at  the  house  (possi- 
bility of  standing  in  the  sun  on  delivery  wagon  for  hours)  ? 
Is  the  milk  simply  boiled,  sterilized,  pasteurized,  or 
administered  raw  ?  Length  of  sterilization  ?  Method  of 
])reservation,  whether  kept  near  sick  room  ?  Mode 
of  mixing  milk  and  character  of  ingredients.  Total 
amount  of  liquids  taken  daily  ?  Amount  of  pure  milk  ? 
Size  of  individual  meals ;  intervals  between  drinking. 
Form  of  bottle,  of  nipple;  size  of  the  holes  of  the  latter. 
The  care  of  the  whole  feeding  apparatus. 

THE  PROPER  METHOD  OF  EXAMINING  A  CHILD 

In  recording  a  certain  case  the  following  plan  should 
be  followed :  I.  Temperature,  pulse,  respiration.  II. 
Nourishment  and  development.  III.  Skin.  IV.  Glands. 
V.  Api>aratusof  locomotion.  VI.  Nervous  system  and 
organs  of  special  sense  (sensorium,  reflexes).  VII.  Phar- 
ynx, nose.  VIII.  Organs  of  circulation.  IX.  Respira- 
tory organs.  X.  Abdominal  organs  (stomach,  liver, s])leen, 
intestines,  and  genitalia).     XI.  Urine.     XII.  Stools. 


62 


EXAMIXATION  AND  HISTORY 


At  first,  before  disturbing  the  child,  a  general  insjieetion 
is  made  ;  if  the  infant  is  awake  delay  the  examination 
until  it  has  become  accustomed  to  the  physician's  presence 


Fig.  9.— DiaRram  for  recording  the  findings  in  the  examination  of 
children  iiji  to  four  years  of  age.  (According  to  the  exact  cadaver  meas- 
urements of  Trumpp.) 

and  employ  the  time  asking  the  most  important  questions, 
and  in  observing  the  child  with  as  little  annoyance  as 
possible. 


PROPER  METHOD   OF  EXAMINING  A   CHILD     53 

Note  :  A  ceaseless  drawing  up  of  the  legs  with  loiid 
cries  and  painful  distortion  of  the  face  in  sleep  indicates 
pain  in  the  abdomen  ;  rubbing  the  head  on  the  pillow 
points  toward  craniotabes  or  otitis  media ;  in  the  latter 
case,  there  is  usually  high  fever.  The  failure  of  volun- 
tary motion  when  the  child  is  awake  is  a  sign  of  weak- 
ness, stupor  (opiates),  or  imbecility.  Characteristic 
appearance  of  the  face  in  meningitis  (sickly,  painful, 
squint) ;  in  whooping-cough  (puffiness  in  the  neighbor- 
hood of  the  eyes,  protrusion  of  eyeballs) ;  in  vegetative 
adenoids  (somewhat  stupid,  open  mouth,  obliteration  of 
nasolabial  folds). 

After  the  pulse  and  respiration  have  been  controlled, 
inspection,  which  plays  a  very  important  role  in  children, 
is  undertaken.  This  is  followed  by  thermometry,  palpa- 
tion, auscultation,  percussion,  mensuration,  and  examina- 
tion of  the  excretions.  The  respiration  can  only  be 
studied  when  the  child  is  asleep  or  absolutely  quiet.  We 
note  its  frequency,  depth,  regularity,  and  character,  which 
is  snorting  in  case  of  vegetative  adenoids,  impeded  in 
tonsillitis,  gurgling  in  retropharyngeal  abscess,  contraction 
of  the  jugulars  in  stenosis  of  the  upper,  and  contraction 
of  the  costal  arch  in  stenosis  of  the  lower,  air-passages. 
The  pulse  is  likewise  best  observed  when  the  child  is 
asleep.  It  is  to  be  noted  that  a  considerable  increase  in 
the  rate  may  follow  the  slightest  cause,  even  in  healthy 
subjects.  The  observation  includes  mainly  the  frequency, 
regularity,  tension,  and  size.  The  pulse  is  slower  than 
normal  at  the  commencement  of  meningitis,  during  the 
convalescence  from  infectious  diseases,  and  in  weakening 
conditions.  The  pulse  is  accelerated  in  fever,  in  excite- 
ment, and  in  the  terminal  stage  of  meningitis.  The  pulse 
is  irregular  (also  unequal)  in  certain  intestinal  diseases — 
influenz.i,  diphtheria,  myocarditis,  and  in  meningitis,  even 
at  the  beginning. 

While  the  child  is  still  in  bed  the  tem[)erature  is  taken. 
This  is  always  done,  without  exception,  per  rectum,  and 
is  determined  by  passing,  high  up  into  the  rectum,  the 
thermometer  which  has  been  cleansed  with  alcohol  and 


54 


EXAMINATION  AND  HISTORY 


lubricated  with   fat,  soap,  or  water.      This  act  may  be 
accomplished  with  greater  ease  by  drawing  the  legs  of  tlie 


INSPECTION  55 

child  tightly  against  the  abdomen.  So-called  "  minute  " 
or  "  half-minute  "  thermometers  are  to  be  employed,  and 
the  first  result  controlled  by  a  second  test. 

For  further  examination  it  is  absolutely  necessary  to 
remove  the  child,  undressed,  from  the  bed.  The  infant 
is  held  either  on  the  lap  of  its  mother  or  on  an  upholstered 
table  with  its  face  toward  the  light. 

INSPECTION 

We  next  note  the  general  appearance  and  state  of 
nutrition,  expression  of  the  face,  posture,  and  abnormal 
movements.  In  inspecting  the  skin  observe  the  peculiar 
cyanotic  pallor  of  pneumonia ;  the  pale  to  dirty  yellow, 
somewhat  shiny  color  in  hereditary  syphilis  ;  the  sickly 
and  dry  condition  in  diseases  of  the  thyroid  gland  ;  the 
cyanosis  of  laryngeal  stenosis,  miliary  tuberculosis,  and 
heart  failure  ;  the  edema  in  nephritis  ;  minute  extravasa- 
tions of  blood  as  unfavorable  prognostic  signs  in  certain 
diseases,  especially  in  those  of  the  intestines,  in  diphtheria. 
Various  diseased  states  must  be  distinguished  from  insect 
bites,  which  are  red  with  central  points,  sudamina,  and 
the  erythema  which  follows  applications. 

The  skin  and  the  pad  of  fat  in  the  region  of  the  anus 
point  to  the  general  state  of  nutrition  ;  intertrigo  in 
severe  diarrhea  ;  rhagades  in  chronic  constipation  and  in 
syphilis. 

Papules  in  eczema  and  syphilis.  Also  observe  the 
general  form  of  the  body  and  of  its  diiferent  parts 
(deviation  of  the  vertebrse,  deformities,  contractures),  and 
also  the  posture  and  gait. 

Inspection  of  the  oral  cavity  is  not  to  be  neglected  in 
any  case,  but  should  be  delaye<l  until  the  end  of  the 
examination.  It  is  to  be  performed  with  the  infant  in  the 
lap  or  arms  of  the  mother.  The  physician  stands  either 
in  front  of  or  behind  the  child  and  presses  the  tongue 
with  a  spatula  or  spoon  until  a  swallowing  movement 
occurs,  which  brings  the  posterior  pharynx  into  view. 
If  it    is    impossible   to  open    the  mouth  because  of  the 


56 


EXAMINATION  AND  HISTORY 


Fig.  11. — Inspection  of  the  oral  cavity  of  a  small  child.  The  hands 
are  firmly  fixed.  The  physician'.s  left  hand  holds  the  head  and  jjnidcs  it 
toward  the  light.  The  inspection  may  also  be  performed  as  in  Fig.  12, 
the  nurse  holding  the  infant  on  her  lap. 

strong  resistance  offered  by  the  child,  we  should  patiently 
try  to  enter  the  mouth  back  of  the  molar  teeth.  Hold- 
ing the  nose  shut  in  order  to  force  the  child  to  open  its 


INSPECTION 


57 


Fig.  12. —  Inspection  of  the  oral  cavity  with  tlie  physician  standing 
back  of  the  child.  This  position  is  a  better  protection  against  the  cough, 
but  requires  more  practise  to  see. 


68  EXAMINATION  AND  HISTORY 

mouth  is  of  no  avail.  It  will  only  serve  to  excite  the 
child,  who  can  finally,  even  without  opening  the  mouth, 
breathe  through  the  tooth  spaces.  During  the  short  time 
which  is  at  our  disposal,  we  note  the  color  and  any  eruj>- 
tion  that  may  be  present  on  the  hard  and  soft  palates,  the 
condition  of  the  tonsils  and  posterior  wall  of  the  pharynx, 
and  any  deposit  which  may  be  on  these  parts. 

The  presence  of  a  tonsillar  or  retropharyngeal  abscess 
must  not  be  overlooked  under  any  circumstances.  If  it 
is  suspected,  the  oral  cavity  must  be  palpated.  Inspec- 
tion of  the  teeth  with  reference  to  their  number,  develop- 
ment, form,  and  position  should  take  place  either  before 
or  after  viewing  the  pharynx. 

«•  PALPATION 

By  passing  the  flat  hand  over  the  surface  of  the  body 
a  superficial  idea  may  be  obtained  of  its  temperature  (but 
only  the  thermometer  should  be  trusted).  The  skin  is 
tested  as  to  its  moisture  or  dryness.  It  is  moist  when  a 
fever  is  on  the  decline,  dry  in  profuse  watery  diarrhea,  in 
disease  of  the  thyroid  gland,  and  in  increasing  fever. 
If  on  inspection  any  discoloration  or  change  in  form  is 
noticed,  it  is  further  examined  by  palpation.  Edema  and 
papular  exanthems  can  only  be  determined  positively  in 
this  manner;  erythema  and  roseola  can  only  be  distin- 
guished from  hemorrhages  by  their  disappearance  upon 
pressure.  Then  follows  a  systematic  palpation  of  the 
whole  body  from  the  head  downward.  From  the  large 
fontanels,  where  the  size  of  the  opening,  the  degree  of 
tension,  and  the  character  of  the  borders  are  noted,  the 
hand  passes  to  the  occi})ut.  The  latter  is  grasped  in 
both  hands  and  with  pressure  exerted  by  the  fingers  we 
detect  softened  areas  (craniotabes).  The  fingers  passing 
over  the  two  lateral  fontanels  exert  pressure  upon  the 
tragus  and  the  posterior  auricular  region,  to  exclude 
severe  affections  of  the  ear  (otitis  media,  mastoiditis). 
Next  the  pal])ating  hand  examines  the  lower  jaw,  the 
posterior  and  lateral  cervical   region,  as  well  as  the  two 


PALPATION 


59 


60  HISTORY  AND  EXAMINATION 

Fig.  14. — Palpation  of  the  liver  from  above.  Tlie  organ  may  be 
pressed  downward  with  light  pressure  exerted  by  the  ball  of  the  hand. 
Palpation  may  also  be  performed  from  below. 


supraclavicular  fossae  and  the  lymph-nodes  which  are 
found  in  that  neighborhood.  Note :  Acute  enlargement 
of  the  glands  in  diphtheria,  scarlet  fever,  stomatitis,  and 
abscesses  ;  chronic  enlargement  in  scrofula,  eczema  of 
the  head,  caries  of  the  teeth.  Enlarged  supraclavicular 
nodes  are  of  importance  in  latent  tuberculosis. 


II  tLturkk 


Fig.    15. — Bimanual   palpation  of  the  spleen   from  below  upward. 
Counterpressure  is  exerted  upon  the  spleen  with  the  left  baud. 

In  the  thorax  the  borders  of  the  cartilages  of  the  ribs 
are  felt  and  physiologic  enlargement  distinguished  from 
the  rachitic  swelling.  In  palpating  the  abdomen  the  child 
should  lie  upon  its  back.  The  hand,  which  should  be 
relaxed  and  held  as  flat  as  possible,  is  slowly  and  gently 
pushed  inward.  The  abdomen  is  retracted  in  atrophic 
and  cachectic  conditions  and  in  meningitis  ;  it  is  enlarged 
in  rachitis  and  in  many  diseases  of  the  intestines.  Tender- 
ness exists  in  the  region  of  the  colon  and  in  inflammatory 
processes  of  the  lower  section  of  the  intestines.  The 
ileocecal  area  should  always  be  examined  for  tenderness 
and  resistance.  Ileocecal  gurgling  is  a  frequent  phenom- 
enon in  children.  To  detect  free  liquids  in  the  abdominal 


PALPATION 


61 


Fig.  14. 


62 


HISTORY  AND  EXAMINATION 


cavity  gently  tap  with  the  right  middle  finger  and  receive 
the  wave  with  the  point  of  the  left  finger. 

The  spleen  is  i)alpated  in  two  ways  (compare  Figs.  13 
and  15).  Be  careful  not  to  mistake  the  lower  ribs  for 
that  organ.  The  same  conditions  hold  true  for  paljjation 
of  the  liver.  Finally,  the  extremities  are  palpated  for 
swellings,  bony  exostoses,  tenderness,  abnormal  or  dimin- 
ished motility,  paralyses,  spasms,  etc. 


Fig.  16. — Auscultation  with  the  double  stethoscope.  Advantages: 
The  area  to  be  auscultated  is  visible,  the  child  islessdisturlx'd,  and  there 
is  greater  magnification  of  the  sounds.  Disadvantages:  Neigliboring 
sounds  are  more  distinctly  heard,  and  it  is  necessary  to  renew  the  tubes 
in  the  course  of  time. 


AUSCULTATION  63 

AUSCULTATION 

It  is  desirable  tliat  the  ciiild  be  kept  as  quiet  in  this  pro- 
cedure as  in  percussion,  but  it  is  not  an  absolute  necessity. 
The  crying  is  of  use  in  determining  the  vocal  resonance 
and  fremitus.  The  respiratory  murmur  itself  can  in  that 
case  only  be  heard  during  the  short  inspiration.  Whether 
auscultation  precedes  percussion  or  vice  versa,  dej)ends 
upon  which  is  the  most  unpleasant  to  the  child.  (It  is 
wise  to  proceed  gradually  with  the  least  pleasant  exami- 
nations.) Auscultation  of  the  lungs  may  be  performed 
in  various  ways:- At  first  with  the  bare  ear — for  thus  the 
sounds  are  purer  and  clearer — and  then,  to  control  the 
results  of  that  method,  by  means  of  a  stethoscope.  The 
binaural  stethoscopes  are  almost  exclusively  used  in  this 
country,  and  are  to  be  recommended  (Fig.  16).  It  is  to 
be  noted  that  normal  bronchial  breathing  is  heard  on 
either  side  of  the  spinal  column,  and  that  frequently 
crepitant  rales  are  heard  at  the  beginning  of  the  exami- 
nation on  account  of  the  forcing  of  air  into  parts  which 
were  previously  atelectatic. 

Auscultation  of  the  heart  should  always  be  performed 
with  the  stethoscope,  for  it  cannot  very  well  be  outlined 
or  localized  in  any  other  way.  (For  the  normal  relation- 
ship of  a  child's  heart,  see  Diseases  of  the  Heart.) 

PERCUSSION 

Either  finger  or  hammer-pleximeter  percussion.  The 
latter  is  to  be  done  only  with  a  light  Curschmann's 
hammer.  Various  forms  of  finger  percussion  are  distin- 
guished, all  of  which  are  best  employed  one  after  the 
other. 

Direct  Percussion  of  Bones. — The  point  of  the  middle 
finger  percusses  anteriorly  the  clavicles  at  symmetric 
points,  and  posteriorly  the  spines  of  the  scapulae. 

Palpatory  Percussion. — The  four  fingers  of  the  right  or 
left  hand  ]>ercuss  directly  the  posterior  wall  of  the  thorax 
in  symmetric  areas.  These  two  methods  of  percussion 
are  useful  in  making  a  rapid  examination. 


64 


HISTORY  AND  EXAMINATION 


The  Usual  Method  of   Percussion,  Finger  on  Finger. — 
This  is  not  performed  as  in  adults — with  relaxed  wrist- 


FiG.  17. — Manner  of  liokliug  and  fixing  a  child  in  ant<jii<ii-  jicrciissiou. 
The  same  holds  true  for  percussion  of  the  back.  The  hotly  should  be  in 
as  symmetric  a  posture  as  possible. 

joint  and  with  an  elastic  and  hammering  movement — but 
with  light  pressure  of  the  percussing  fingers  and,  as  in  pal- 


PERCUSSION 


65 


pat  ion,  with  the  middle  finger  of  the  left  hand  applied 
closely  and  as  lightly  as  possible,  palpating  at  the  same 


Fig.  18. — Percussion  of  the  back  while  the  diild  is  held  in  the  arms  of 
the  nurse.     Position  as  syiniuetric  as  possible. 


time.     Heavy  blows   incliido  too  large   portions  of  the 
body  in  the  resonance  and  must  be  absolutely  avoided.    . 
5 


66  HISTORY  AND  EXAMINATION 

For  }>ercussion  the  child's  body  must  be  held  as  sym-. 
metrically  as  possible,  since  slight  asymmetries  of  pos- 
ture cause  changes  in  the  sound  elicited.  The  finger 
which  acts  as  the  pleximeter  must  be  always  placed  on 
symmetric  parts.  Since  in  children  the  sounds  are  de- 
cidedly influenced  by  the  respiration,  it  is  impossible  to 
always  percuss  both  sides  during  at  least  one  whole  res- 
piratory period. 

It  should  be  borne  in  mind  that  the  lower  border  of 
the  right  lung  is  higher  because  of  the  liver,  which  is  not 
rarely  mistaken  for  pulmonary  dulness.  On  the  left  side 
remember  the  close  proximity  of  gastric  tympany  to 
the  edge  of  the  lungs.  Examination  of  the  axillary 
regions  is  of  the  greatest  importance ;  bronchopneumonic 
foci  are  frequently  detected. 

Finger-nail  upon  finger-nail  for  very  light  percussion, 
especially  for  the  spleen  and  thymus. 

Auscultatory  percussion  by  the  simultaneous  application 
of  the  stethoscope  or  phonendoscope. 

MENSURATION 

For  weighing  the  child,  either  a  decimal  or  one  of  the 
so-called  "infant's  scales,"  fitted  with  a  bowl,  is  employed. 
The  spring  scales,  to  which  the  child  is  hung  in  a  bag, 
are  ex|)ensive  and  unreliable.  The  s])ring  kitchen  scales 
are  useless.  Infants  should  be  weighed  once  every  week, 
larger  children,  every  month.  For  the  physician  the 
scales  are  indispensable  in  estimating  deviations  from 
normal  development. 

Linear  Measurement. — Infants  are  held  stretched  on  a 
table  in  the  dorsal  position  and  measured  from  heel  to 
crown.  Large  children  are  measured  standing  against  a 
wall  or  with  a  vertical  measuring  staff,  which  is  supplied 
with  a  movable  transverse  arm.  The  linear  measure- 
ment is  also  of  value  in  determining  normal  and  abnor- 
mal development,  especially  in  rachitis,  hypothyroidism, 
hereditary  syphilis,  etc. 


THE  SECRETIONS  AND  EXCRETIONS  67 

THE  SECRETIONS  AND  EXCRETIONS 

The  secretions  from  the  conjundivce  are  examined  for 
diphtlieria  bacillus  and  gonococci ;  the  secretion  from 
the  nose,  for  influenza  or  diphtheria  bacilli.  With  a 
platinum  wire,  which  has  been  previously  brought  to  a 
red  heat,  minute  drops  are  secured  from  the  secretion  and 
rubbed  upon  the  cover-glass ;  the  sjjutum  (removed  with  a 
cotton  swab  or  aspirated)  is  examined  for  its  macroscopic 
characteristics,  and  microscopically  for  elastic  fibers,  influ- 
enza, diphtheria,  and  tubercle  bacilli.  Deposits  in  the 
mouth  or  pharynx  are  removed  in  minute  particles,  either 
with  a  platinum  rod  which  has  been  passed  through  a 
flame,  with  sterile  forceps,  or  with  a  small  cotton  tampon. 

For  these  as  well  as  for  the  succeeding  examinations 
proceed  as  follows:  At  first  examine  the  unstained  prep- 
aration mixed  with  a  drop  of  water  and  then  dry  and 
stain  it. 

The  urine  is  examined  for  its  amount,  specific  gravity, 
color,  reaction,  cloudiness  (bacteriuria,  cystitis,  phospha- 
turia),  albumin,  sugar,  blood,  biliary  coloring-matter, 
indican,  and  the  diazo-reaction.  It  is  obtained  from 
infants  either  with  specially  constructed  vessels^  or  by 
means  of  catheterization  (especial  care  is  required  in  the 
case  of  boys).  It  may  be  obtained  from  a  sleeping  male 
child  by  simply  catching  it  in  an  ordinary  reagent  glass. 
For  determining  the  exact  quantity  of  urine  excreted  the 
apparatus  of  Bendix  and  others  may  be  employed. 

The  feces  are  examined  macroscopically  for  the  amount, 
color,  consistence,  odor,  reaction,  abnormal  ingredients, 
mucus,  serum,  pus,  blood,  and  remnants  of  food ;  micro - 
scojiically  for  bacteria,  pus-corpuscles,  fat,  starch  (colored 
blue  with  Lugol's  sohition),  fungi,  tissue  cells,  amebae, 
parasites  and  their  ova. 

The  cerebrospinal  fluid  is  examined  as  to  color,  reaction, 
specific  gravity,  amount  of  albumin,  sugar,  bacteria,  and 
pus-corpuscles.  It  is  obtained  by  means  of  Quincke's 
lumbar    puncture.     The    child    lies    upon    its   side   or 

1  Compare  Diseases  of  the  Kidneys. 


68        MANAGEMENT  OF  DISEASE  IN  CHILDREN 

assumes  the  sitting  posture ;  the  spinal  cohimn  is  curved 
forward  as  much  as  possible ;  a  sterile  needle  about  7  cm. 
[2.8  in.]  long  is  introduced  with  the  point  turned  sliglitly 
upward  in  the  middle  line  between  the  4th  and  5th  or  the 
3d  and  4th  lumbar  vertebra  to  a  depth  of  from  2  to  4 
cm.  [.8-1.6  in.],  until  the  point  of  the  needle  is  freely 


■*^¥24r 


Fi(r.  19. — Quincke's  lumbar  puncture.  A  line  drawn  Ironi  one  iliac 
crest  to  the  other  will  cross  the  spine  between  the  4th  and  5th  lumbar 
vertebrse.  The  puncture  may  be  performed  while  the  child  is  in  the  sit- 
ting posture. 

movable.  The  pressure  of  the  spinal  fluid  is  measured 
by  connecting  the  needle  by  means  of  a  thin  rubber  tube 
to  a  manometer.  The  normal  pressure  equals  that  of 
from  40  to  130  mm.  [1.6-5.2  in.]  of  water.  The  opera- 
tion is  free  from  danger  if  it  is  performed  in  an  antiseptic 
manner. 

GENERAL  MANAGEMENT  OF  DISEASE 

IN   CHILDREN 

DIETETIC   TREATMENT 

The  most  important  factor  is  cjireful  attention  to  the 
diet  and  hygiene.  Breast-fed  children  when  sick  should 
continue  to  receive  nourishment  from  the  breast  if 
practicable.  Hand-fed  children  should  in  acute  cases 
have   their  diet  reduced.     In  disturbances  of  digestion 


HYDROTHERAPY  69 

some  bland  fluid  should  be  given  which  practically 
requires  no  digestion,  such  as  water,  dilute  tea,  or  a  very- 
thin  cereal  water  ;  albumin-water  (the  white  of  one  egg 
beaten  up  and  stirred  in  ^  liter  of  cool  water,  then 
•strained  and  sugar  added);  watery  flour  broths  ;  5  to  10 
per  cent,  solutions  of  nutritive  sugar. 

Drinks  for  sick  children  are  cold  water,  with  or  without 
fruit  juices,  toast- water  (toasted  wheat  bread  over  which 
hot  water  is  poured,  with  the  addition  of  sugar  and,  if 
desired,  lemon-juice),  sugar- water,  almond- water,  and 
cold  teas. 

As  a  non-irritating  diet  are  recommended  :  Milk 
diluted  or  with  the  addition  of  other  elements,  flour  broth, 
infant's  food  soups.  For  larger  children  give  vegetable 
and  potato  broths,  jellies,  fresh  minced  meat,  buttermilk, 
zwieback,  soft  eggs,  light  pastry,  fruit,  gelatin,  and 
gruels. 

As  a  diet  capable  of  giving  strength  in  chronic  sick- 
ness give  foods  rich  in  fat  and  sugar,  cream,  cereals, 
minced  chicken,  squabs,  veal,  ham,  sausage,  calves'  brains, 
broths,  beef-tea,  eggs,  chocolate,  extract  of  malt,  cocoa, 
and  cold  oatmeal  gruel.  In  case  of  weakness  give  com- 
pressed meat  juice,  meat  jellies,  beef-tea,  strong  bouillon, 
tea,  champagne,  wine,  and  port  wine. 

To  stimulate  the  appetite  give  undiluted  Valentine's 
meat  juice,  meat  gravies,  caviar,  and  sardines.  Of 
medicines  give  wine  of  cinchona,  the  compound  tincture 
of  cinchona,  and  ichthalbin. 

The  remaining  hygienic  directions,  which  in  general  are 
like  those  observed  in  adult  life,  are  best  given  in  greater 
detail,  for  especial  attention  should  be  paid  to  cleanliness 
of  the  mouth,  eyes,  nose,  and  skin  ;  preventing  wetting  of 
the  bed ;  the  clothing;  the  temperature  (15°  to  18°  C. 
[59°-64.5°  F.]). 

HYDROTHERAPY 

Sick  children  are  treated  with  hydrotherapeutic  pro- 
cedures to  meet  the  followiuir  indications  :  To  reduce  the 


70        MANAGEMENT  OF  DISEASE  IN  CHILDREN 

fever,  to  increase  tlie  coiKluctivity  of  the  skin,  to  regu- 
late tiie  circulation,  and  to  increase  aljsorption.  Water  is 
employed  as  a  counter-irritant,  especially  for  the  nervous 
system,  respiration,  and  pulse  ;  and  also  as  a  sedative. 

The  following  baths  are  recommended  : 

Hot  baths  (37°  to  40°  C.  [98.6°-104°  F.])  as  a  prelude  to 
sweating  processes,  to  increase  the  temperature  of  the 
body  (as  an  analeptic  in  diseases  of  the  intestines),  and  to 
relieve  the  action  of  the  heart. 

Warm  baths  (33°  to  35°  C.  [91.4°-95°  F.])  for  cleanli- 
ness ;  at  the  beginning  of  febrile  diseases ;  for  a  sym- 
metric distribution  of  heat,  and  as  a  sedative. 

Cool  baths  (31°  to  27°  C.  [87.8°-80.6°  F.])  to  diminish 
fevers  ;  to  stimulate  and  deepen  respiration  ;  in  nervous 
diseases,  especially  with  simultaneous  vigorous  rubbing. 

The  most  useful  additions  to  baths  are  :  Aromatic  solu- 
tions of  camomile,  fennel  (1  to  2  handfuls  in  a  linen 
sac  over  which  hot  water  is  poured) ;  wheat-bran,  oak-bark 
as  an  astringent  (3  to  5  haiidfids  boiled  in  a  sac);  salt  or 
brine  (cooking  salt  or  sea  salt,  200  gm.  to  a  pail  of  water); 
mustard  as  a  strong  stimulant  (5  teaspoonfuls  of  black 
mustard  in  a  linen  bag  over  which  boiling  water  is  poured, 
and  allowed  to  stand  for  several  minutes) ;  sublimate  (0.5 
to  1.0  gm.  per  bath) ;  peat  soil  or  peat  salt  (15  kg.  of  the 
former  and  30  to  40  gm.  ofthelattcr);  sulphur  (15  to  25  gm. 
sulphuret  of  potash  dissolved  with  hot  water  in  a  bag). 

Applications. — Cooling  applic-iitions  made  of  linen  cloth 
and  covered  by  a  larger  woolen  cloth,  without  interposing 
an  imjjermeable  layer.  These  are  applied  most  frequently 
to  the  chest  and  trunk,  more  rarely  to  the  whole  body,  for 
the  purpose  of  diminishing  the  temperature,  as  a  sedative 
and  to  increase  conduction  ;  care  must  be  taken  not  to 
let  them  remain  in  place  longer  than  fnmi  one-half  to  two 
hours.  A  satisfactory  antipyretic  action  is  obtained  at 
the  beginning  by  changing  the  application  every  quarter 
hour  and,  later,  every  half  hour. 

Hydropaihie  applications  are  made  with  linen,  water- 
tight material,  or  woolen  cloth.  The  action  is  a  sedative 
to  pain  and  resorbent ;  they  may  remain  in  place  from 


MEDICINAL   TREATMENT  71 

three  to  ten  hours.  The  water  used  in  all  of  these  appli- 
cations has  a  temperature  of  from  16°  to  20°  R.  [70°- 
77°  F.] — "  room  temperature." 

Hot  Stupes. — Linen  cloths  boiled  in  water,  removed 
with  spoons,  wrung  out  in  a  second  linen  cloth,  and  then 
rapidly  applied,  covered  with  a  woolen  cloth  and  left  in 
place  from  a  quarter  of  an  hour  to  an  hour.  These  are 
em{)loyed  in  sepsis  and  diseases  of  the  heart  and  kidneys. 

Mustard  Poultices. — One  liter  of  boiling  water  poured 
on  1  pound  of  powdered  mustard,  stirred  until  the 
mustard  odor  arises,  soak  a  linen  cloth  in  the  mustard- 
water  which  has  been  poured  off  the  above  mixture,  and 
apply  it  to  the  body,  allowing  it  to  remain  in  place  one- 
half  hour.  Follow  it  by  washing  with  cool  water,  and 
later  by  applying  cool  applications.  A  vigorous  counter- 
irritant  in  bronchopneumonia. 

Cold  sprays  of  18°  to  22°  R.  [72°-81.5°  F.]  are  used 
upon  the  neck  and  chest,  usually  a  warm  or  cool  bath,  for 
the  purpose  of  stimulation,  especially  of  the  respiratory 
center;  also  used  independent  of  a  bath  in  hysteria, 
epilepsy,  and  enuresis. 

Cold-water  bathing,  also  bathing  sometimes  with  brandy 
or  eau  de  Cologne,  are  of  use  to  refresh  the  body  and  to 
stimulate  metabolism. 

To  stimulate  perspiration  employ  either  hot  baths  or  dry 
hot  packs,  or  pack  the  whole  body ;  the  latter  is  done  by 
placing  three  or  four  jugs  containing  hot  water  in  the  bed 
wrapped  in  wet  cloths.  This  treatment  is  supplemented 
by  the  administration  of  hot  lemonade  or  tea. 

MEDICINAL  TREATMENT 

Medicinal  treatment  is  to  be  resorted  to  only  to  meet 
exact  indications.  The  most  convenient  form  is  either  the 
liquid  or  powder,  although  small  pills,  capsules,  and  gran- 
ules uay  be  used.  Tablets  must  be  crushed  before  use. 
The  taste  is  alwavs  to  be  considered,  and  to  dis<2:uise  it 
give  smiple  syrup  or  sugar-water  to  each  individual  dose. 
Bud-tasting  medicaments  must  not  be  given  in  the  food, 
for  the  latter  will  thus  partake  of  the  disagreeable  taste ; 


72        MANAGEMENT  OF  DISEASE  IN  CHILDREN 

insoluble  powders  may  be  given  in  a  thick  gruel  or  cocoa  ; 
bromid  or  iodid  solutions  in  cold  milk  ;  quinin  in  slightly 
sweetened  cocoa  ;  bromqform  in  the  yelk  of  an  egg ;  castor 
oil  heated  in  a  warm  spoon  or  dusted  with  sugar,  or  in 
bouillon  or  raspberry  juice. 

Dosage. — As  a  general  rule,  give  as  many  twentieths 
of  the  average  adult  dose  as  the  child  is  years  old  (Neu- 
mann). 

Measurements. — One  coifeespoon  =  5gm.;  1  children's 
spoon  =  8  to  10  gm.;  1  tablespoon  =  15  to  20  gm.;  the 
most  useful  are  the  graduated  medicine-glasses. 

In  the  use  of  different  remedies  (narcotics),  especially 
during  the  nursing  age,  great  foresight  must  be  practised, 
and  it  is  always  safest  to  first  give  a  small  test-dose. 

Aside  from  administration  by  the  mouth,  medicines 
may  also  be  given  by  subcutaneous  injections,  by  encmata 
(in  amounts  from  15  to  25  gm.,  lukewarm),  for  gastric  and 
intestinal  irrigation ;  externally  in  inunctions,  gargles, 
painting,  insufflations,  etc. 

Expectorants. — Radix  ipecacuanhse  in  infusions,  0.2  to 
0.3  :  100.0  ;  liquor  ammonii  acetatis,  1  to  2  ])er  cent.,  as  a 
supplement  to  mixtures;  sodium  bicarbonate,  2  percent.; 
radix  senega,  3  to  5  per  cent.,  in  decoctions  (for  irritating 
coughs);  acidum  benzoicum,  0.03  per  dose,  with  an  equal 
amount  of  camphor;  ajwmorphinum  hydrochloricum, 
0.005  to  0.03;  terpin  hydrate,  0.1  to  0.25;  creosotal, 
3  X  3  to  10  gtt. ;  vapor  inhalations  and  damp-cloth  hang- 
ings. 

Laxatives. — For  nursing  infants,  magnesia,  just  enough 
to  cover  the  point  of  a  knife  to  a  dose ;  powdered  mag- 
nesia with  rhubarb,  a  like  dose  ;  syrup  manna^,  syrup  of 
cascara  sagrada,or  syrup  of  rhubarb,  coffbespoonful  doses; 
castor  oil  in  coffeespoonful  doses  ;  calomel,  0.001  to  0.04. 
For  older  children  give  castor  oil  in  doses  of  from  a  coffee- 
spoonful  to  a  tablcspoonful ;  tamarind  ;  infusion  sennae 
comp.  in  children's  spoonful  doses ;  ]>urgen  and  baby 
purgen,  one  or  two  tablets,  califig  in  coffeespoonful 
doses  ;  folliculi  .seniue  (5  to  10  leaves  boiled  for  one-half 
minute) ;  Barber's  sagrada  tablets  ;  the  neutral  salts. 


MEDICINAL  TREATMENT  73 

Astringents. — Alumin.  acetic,  internally,  ,5  per  cent. ; 
externally,  2  to  4  per  cent. ;  silver  nitrate,  .04  per  cent., 
internally  ;  3  per  cent,  decoctions  of  calumba  roots ;  bis- 
muth salicylate,  3  to  5  per  cent.;  tannigen,  0.05  to  0.5  per 
dose  ;  tannalbin,  0.25 ;  tincture  of  veratrum,  0.1  :  5.0  ; 
diluted  spirits,  3  to  10  gtt.  every  hour ;  5  per  cent,  decoc- 
tions of  the  leaves  of  uva  ursi ;  5  per  cent,  infusion  or 
the  fluidextract  of  the  leaves  of  jambul. 

Emetics. — A  coffeespoonful  of  the  infusion  of  the  root  of 
ipecacuanha,  1.0  to  2.0:50.0,  every  ten  minutes  ;  powdered 
ipecac,  1.0  to  2.0  :  50.0;  syrup  of  althaea;  apomorphin 
hydrochlorate,  0.0008  to  0.003,  subcutaneously. 

Narcotics. — Aquje  amygdalae  amarse,  1.0  :  100.0;  co- 
dein  pliosphate,  -^  to  \  mg.,  for  nursing  infants,  later 
0.005  to  0.05 ;  heroin  hydrochlorate,  ^  to  ^  mg.  per  dose ; 
tincture  of  opium,  not  before  the  third  month ;  at  one 
year,  \  drop  per  day ;  at  two  years,  1  gtt. ;  from  two  to 
four  to  ten  years,  1  to  2  to  5  drops  per  dose ;  morphin 
hydrochlorate  should  not  be  given  until  after  the  third 
year,  0.001  per  dose ;  chloral  hydrate,  0.1  to  0.5  by 
mouth,  0.2  to  1.0  by  rectal  injections;  extract  of  bella- 
donna, 0.001  to  0  003  per  dose ;  bromoform,  1  to  6  drops 
three  times  daily  ;  atropin  sulphate,  0  0002  to  0.0003, 
subcutaneously. 

Nervines. — Potassium  bromid,  0.3  per  day,  depending 
upon  the  age  (it  is  best  to  combine  this  with  sodium  and 
ammonium  bromid  and  sodium  bicarbonate  ;  the  latter  is 
given  in  double  doses).  Erlenraayer's  bromid  water,  \ 
to  I  to  1  bottle  daily ;  Sandow's  effervescent  bromid 
salts ;  the  muriate  of  quinin,  01  to  0.3  ;  tincture  of  vale- 
rian, 20  to  40  gtt.  per  day. 

Alterants. — Iron  (see  Anemia,  p.  145) ;  arsenic  (ibid.); 
iodin,  externally,  as  tincture  of  iodin ;  iodovasogen, 
potassium  iodid  ointment,  for  internal  use  (see  Scrofula) ; 
mercury  (see  Congenital  Syphilis). 

Stimulants. — Liquor  ammonii  anis,  2  to  5  gtt.;  sweet 
spirits  of  niter,  same  dose;  camphor,  0.01  to  0.03,  inter- 
nally ;  camphor  and  ether,  subcutaneously ;  wine,  cham- 
pagne, and  inhalations  of  oxygen. 


I 


74        MANAGEMENT  OF  DISEASE  IN  CHILDREN 

Diaphoretics. — Pilocaqjiii,  |^  to  3  mg.,  subcutaneoiisly, 
in  double  doses  internally. 

Diuretics  and  Cardiants. — Calcium  acetate,  1  to  2  per 
cent.  ;  diuretin,  0.05  per  dose ;  infusion  of  the  leaves  of 
digitalis,  0.3 ;  100.0,  from  1  teaspoonful  to  1  children's 
spoonful  every  three  hours  ;  tincture  of  strophanthus,  1  to 
3  drops  ;  caffein,  0.1  per  dose. 

For  the  remaining  remedies  refer  to  the  different  dis- 
eases. 

Psychic  Treatment. — This  is  not  a  very  practiciil  thera- 
peutic remedy ;  suggestion,  advice,  j^ersuasion,  deception, 
and  threatening  have  some  effect.  These  are  of  practical 
value  in  chorea,  enuresis,  during  the  convalescence  of 
whooping-cough,  hysteria,  and  disturbances  of  speech. 

Mechano-electric  Therapeutics. — General  and  local  for 
stimulation  of  metabolism,  to  strengthen  diseased  or 
paralyzed  muscles,  to  mobilize  joints,  and  to  scatter  an 
exudate.  The  galvanic  and  faradic  currents  are  employed 
for  the  same  indications ;  also  for  nerve  stimulation,  as 
in  enuresis  and  hysteria. 


DISEASES  OF  THE  NEWBORN 

GENERAL    LOSS  OF  VITALITY  AND 
PREMATURE   BIRTH       . 

Lack  of  development  in  size,  weight,  and  function  of 
the  body  at  the  time  of  birth  usually  exists  in  prematurely 
born  infants,  but  may  also  occur  in  full-term  babies  whose 
]>arents  are  unhealthy,  or  who  themselves  are  already 
diseased. 

Symptoms. — Abnormally  small  and  underweight  chil- 
dren show  prematurity  in  the  nails,  skin,  and  genitalia ; 
their  respiration  and  pulse  can  hardly  be  detected ;  they 
sleep  constantly  ;  react  slowly  to  external  stimulation  ; 
nurse  little  or  none  at  all ;  the  temperature  varies 
between  30°  and  28°  C.  [86°  and  82.4°  F.J;  the  umbilical 
stump  is  slow  in  healing.  The  face  is  small  and  weazened, 
the  voice  weak,  and  the  body  very  sensitive  to  every 
change  in  temperature.  Such  infants  usually  die  from 
scleroderma,  pneumonia,  or  as])hyxiation.  The  possibility 
of  life  exists  only  when  the  weight  at  birth  is  at  least 
1000  gm. ;  by  means  of  careful  nursing  it  is  possible  then 
to  save  one-half,  and  when  the  weight  at  birth  is  greater, 
80  per  cent,  of  such  children  continue  to  live. 

Treatment. — The  a])})lication  and  maintenance  of  heat. 
The  infant  is  wrapped  in  wool,  surrounded  by  hot-water 
bottles,  and  kept  in  a  warm  room  at  a  temperature  from 
18°  to  20°  R.  [72.5°-77°  F.].  The  following  specially 
prepared  brood  chambers  may  be  em]>loyed  :  A  chest 
with  movable  glass  covers,  which  is  lined  with  peat  moss 
and  heated  bricks  placed  underneath  or  upon  the  floor ;  a 
bath-tub  with  double  walls  between  which  hot  water 
flows  (Crede) ;    thermophore  ;  incubator  with  appliances 

75 


76     LOS^  OF  VITALITY  AND  PREMATURE  BIRTH 


FIGURE  20 

I.-V.  Incubator  Room  for  Three  to  Five  Infants.  Escherlch-Pfaundler 
System.— (Original  in  the  Clinic  of  Pfaundler.) 

Explanation  :  The  framework  of  the  incubator  room  is  constructed  of 
iron ;  the  sidesand  roof  are  lined  with  plates  of  cork,  while  the  remainder 
is  simply  glazed.  The  walls  are  coated  on  both  sides  with  enamel  paint. 
The  size  of  the  room  is  large  enough  to  accommodate  a  nursn  or  attendant, 
so  the  infants  need  never  be  removed  and  exposed  to  the  injurious  etfects 
of  a  different  temperature.  The  heat  is  obtained  from  a  system  of  cast- 
iron  tubes  (I.,  a),  which  are  of  solid  capacity.  These  tubes  are  connected 
with  the  hot-water  pipes  of  the  house.  An  extra  stove  (A)  is  set  up  in 
the  wash-room  as  a  reserve.  The  temperature  of  the  room  is  regulated 
as  may  be  desired  between  28°  to  34°  C.  [82.4°-93°  F.]  by  means  of  the 
ventilation  apparatus  (F) ;  an  electric  contact  thermometer  registers 
the  gross  temperature  changes. 

The  fresh  air  enters  the  room  through  a  shaft  (B)  from  without  the 
building  (Park),  passes  through  a  cotton  filter  over  the  heating  pipes, 
and  finally  over  a  moistening  apparatus  which  can  be  regulated  (two 
basins  with  oblique  floors  filled  with  water).  By  filling  the  latter  to  a 
certain  height,  the  atmosphere  in  the  room  may  be  so  regulated  that  it 
will  hold  a  relative  moisture  of  60  per  cent.  The  psychrometer  shows 
then  the  difference  between  the  temperature  of  the  two  thermometers  to 
be  5°  C.  [9°  F.].  The  bed  shai^d  in  common  by  the  infants  rests  on  a 
perforated  metallic  plate  (G),  which  is  surrounded  by  a  railing.  The 
floor  of  the  room  and  of  the  incubator  is  composed  of  xylolith.  The 
other  arrangements  of  the  room  are  shown  on  the  plan  (I.). 


for  regulating  warmth  and  moisture,  and  supplied  with 
an  apparatus  for  heating  and  for  discharging  the  air 
which  is  breathed  (Lion,  Rommel,  and  others);  the  tem- 
perature in  the  incubator  should  be  about  30°  C.  [86°  F.]. 
The  incubator  which  offers  the  greatest  hygienic  advan- 
tages is  that  invented  by  Escherich  and  Pfaundler, 
which,  however,  is  only  adaptable  for  hospitals.  Cliildron 
with  poor  vitality  should  be  frequently  moved  and  rejioat- 
edly  carried  about  every  day  in  order  to  prevent  atelectxisis. 
[Specially  improvised  rooms  and  cabinets  are  in  use  as 
incubators  for  premature  children.  The  details  of  their 
construction  need  not  be  gone  into  here. — Ed.] 

Feeding. — Mother's  milk,  which  is  squeezed  from  the 
breasts,  is  administered  with  a  spoon  through  the  nose. 
If  such  milk  is  unobtainable,  give  the  milk  mixtures  of 
Backhaus,  Voltner,  Biedert,  etc.,  [modified  milk  with  a 
low  per  cent,  of  fat,  sugar,  and  proteids,  e.  r/.,  fat,  0.25 
percent. ;  sugar, 4  per  cent. ;  proteids,  25  to  50  per  cent.]. 


INCUBATOR  ROOM 


77 


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78   LOSS  OF   VITALITY  AND  PREMATURE  BIRTH 


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80     LOSS  OF  VITALITY  AND  PREMATURE  BIRTH 

PLATE  4 

Congenital  Umbilical  Hernia. — The  hernial  sac  is  filled  with  intes- 
tines and  a  portion  of  the  liver.  The  amnion  is  discolored  and  is  becom- 
ing gangrenous.  It  shows  thickened  folds  at  the  junction  with  the 
abdominal  walls.     (Escherich's  Clinic,  Vienna.) 


Tab. 


A 


> 


/ 


x_ 


ACQUIRED   UMBILICAL  HEMNJA  81 

DISEASES  OF  THE  UMBILICUS 

TREATMENT  OF  THE  NORMAL  UMBILICUS 

It  is  best  to  allow  only  a  short  portion  (1^  to  2  cm. 
[.6-.8  in.])  of  the  nmbilical  cord  to  remain.  The  stnmp 
is  covered  with  a  dry  sterile  dressing,  which  is  permeable 
to  the  air  and  which  does  not  cause  any  tension  ;  apply  no 
ointment.  Authorities  have  not  yet  agreed  as  to  whether 
the  child  should  be  bathed  daily — excepting  the  first  bath 
— or  not  until  after  the  cord  has  fallen  off.  At  any  rate, 
the  greatest  cleanliness  must  be  observed  in  bathing  the 
infant.  In  the  case  of  ])remature  births  and  weak  chil- 
dren, on  account  of  their  susceptibility  to  septic  infection, 
it  is  wisest  to  postpone  bathing  until  the  umbilical  cord 
has  healed. 

CONGENITAL  UMBILICAL  HERNIA 

Funicular  Umbilical  Hernia,  Omphalocele. — The  abdom- 
inal wall  around  the  umbilicus  is  the  last  to  close.  If  any 
cause  hinders  this,  the  abdominal  cavity  does  not  become 
enclossd  by  the  union  of  the  walls,  but  only  by  closure 
of  the  peritoneum  and  the  sheath  of  the  timbilical  cord, 
that  is,  the  amnion.  This  thin  covering  is  pressed  for- 
ward by  the  viscera  and  forms  an  umbilical  hernia.  The 
umbilical  cord  is  inserted  at  the  apex  of  the  hernial  sac. 
Within  the  protruding  mass,  which  varies  in  size  from  a 
walnut  to  a  child's  head,  may  be  seen  the  intestines,  and 
frequently  also  the  liver  and  kidneys  ;  at  the  point  where 
the  abdominal  walls  pass  into  the  amnion  a  swollen  ring 
of  tissue  is  formed.  Small  hernias  may  be  cured  with  an 
ointment  and  bandage,  which  cause  the  amnion  to  become 
gangrenous.  Larger  hernias  require  surgical  interven- 
tion. 

ACQUIRED  UMBILICAL  HERNIA 

This  form  of  umbilical  hernia  does  not  occur  until 
after  the  cord  has  dropped  off  and  the  wound  healed. 
Favoring  this  condition  are  insufficiency  of  fat  in  the 
abdominal  walls,  too  great  intra-abdominal  })ressure  when 
crying,  or  difficult  micturition  (phimosis)  and  meteorism. 
6 


8^ 


DISEASES  OE  THE  NEWBORN 


The  thin  umbilical  scar  succumbs  to  tlie  pressure,  the 
umbilical  ring  stretches,  and  the  hernia  is  produced.  At 
first  it  is  temporary  and  occurs  only  ^vhen  the  child  cries 
and  presses  downward,  later,  however,  it  becomes  ])erma- 
nent  The  hernia,  which  usually  contains  a  loop  of  small 
intestine,  varies  in  size  from  that  of  a  pea  to  an  apple ; 
larger  hernias  are  elongated,  pendulous,  and  possess  a 


^^ 


/ 


"i 


nstr^'- 


Fig.  22. — A  mild  form  of  acquired  umbilical  hernia. 

dark  pigmented  tip.  Umbilical  hernias  are  usually  easily 
replaced  and  only  rarely  become  incarcerated. 

Small  hernias  frequently  heal  spontaneously  in  the 
course  of  the  first  or  second  year  of  life  by  contraction 
of  the  umbilical  ring. 

Treatment. — Encourage  spontaneous  cure  by  relieving 
the  ]>ressure  upon  the  umbilical  ring  by  means  of  strips 
of  adhesive  plaster ;  the  reduced  hernia  is  j)ressed  down- 


ACQUIRED    UMBILICAL  HERNIA 


83 


ward  by  two  folds  of  the  skin,  one  from  either  side,  which 
are  kept  in  place  with  a  wide  strip  of  adhesive  plaster 
(5  cm.  [2  in.])  in  such  a  manner  that  their  surfaces  touch 
each  other.  This  strip  reaches  from  one  hypochondrium 
to  the  other.  If  the  plaster,  which  remains  in  place 
when  bathing,  is  protected  during  the  first  few  days  by  a 
cloth  binder,  it  should  last  for  from  one  to  three  weeks. 
When  changing  binders  it  is  advisable  to  clean  the  skin 


Fig.  23. — Band  of  adhesive  plaster  over  an  acquired  umbilical 
hernia.  The  plaster  is  tensely  drawn  and  applied  and  fastened  over  the 
ribs  on  both  sides,  so  that  a  longitudiuai  fold  of  the  abdominal  wall  is 
drawn  over  the  hernia. 

with  ether.  In  place  of  this  dressing  a  small  plate 
made  of  folded  adhesive  plaster,  or  a  cork  plate,  may  be 
employed  ;  it  must  be  at  least  1  cm.  [^  in.]  larger  in 
diameter  than  the  hernial  orifice.  It  is  held  in  place  by 
means  of  two  crossed  strips  of  adhesive  plaster.  The 
treatment  may  usually  be  discontinued  after  .several  weeks 
or  a  month,  yet  healing  may  be  hoped  for  after  even 
several  years.  Hernia-bandages  or  circular  rubl^er  her- 
nia-bands should  be  rejected.  In  case  the  hernia  resists 
this  treatment  or  when  the  opening  is  too  large,  an  oper- 
ation is  necessary,  that  is,  a  radical  operation  or  the  more 
recent  paraffin  injection  method  (Escherich).     The  par- 


84  DISEASES  OF  THE  NEWBORN 

affin  (melting-point  39°  C.  [102.2°  F.])  is  injected  into 
the  hernial  sac  after  the  hernia  has  been  reduced,  after 
which  the  contents  of  the  sac  are  again  allowed  to  pro- 
trude, and  covered  for  a  short  time  with  an  ice  compress. 
The  latter  causes  the  paraffin  to  harden,  and  it  in  turn 
pushes  the  hernia  inward.  A  sterile  dressing  is  applied 
for  several  days. 

UMBILICAL  HEMORRHAGE 

We  distinguish  two  forms  of  umbilical  hemorrhage : 
One  which  occurs  immediately  after  birth  from  a  torn, 
poorly  tied,  and  insufficiently  thrombosed  umbilical  cord ; 
and  the  other  from  the  umbilical  wound,  which  does  not 
occur  until  after  mummification  or  after  the  cord  has 
fallen  off.  The  latter  form  occurs  in  sepsis,  syphilis,  and 
acute  fatty  degeneration.  The  hemorrhage  is  of  a  ])ar- 
enchymatous  character,  and  arises  suddenly  or  gradually  ; 
it  is  not  always  continuous  and  leads,  after  a  few  hours  or 
days,  with  symptoms  of  severe  anemia,  to  death.  The 
pale  red  blood  shows  no  tendency  to  coagulate. 

Treatment. — The  first  form  of  hemorrhage  is  usually 
controlled  by  early  ligation,  but  the  second  form  is  usually 
fatal.  The  treatment  consists  in  instituting  the  following 
procedures  :  Tampons  of  chlorid  of  iron  ;  digital  com- 
pression ;  suture  of  the  umbilicus  (Dubois) ;  filling  the 
umbilical  groove  with  plaster  of  Paris  (Hill) ;  clamping 
of  the  umbilicus  with  forceps  (Fischl) ;  gelatin  externally 
and  subcutaneously  ;  and  adrenalin  (1  :1000)  subcutane- 
ously.  [The  local  treatment  by  chlorid  of  iron  and 
digital  compression  is  unavailable  in  most  cases.  Suture 
and  plaster  of  Paris  have  been  recommended.  Gelatin 
has  been  recently  reported  on  favorably.  Adrenalin  has 
also  given  favorable  results  applied  locally. — Ed.] 

UMBILICAL  FUNGUS.     UMBILICAL  GROWTHS 

An  umbilical  fungus  is  due  to  an  excessive  develop- 
ment of  the  granulation  tissue,  which  occurs  normally  in 
conjunction  with  the  healing  of  the  wound.     These  are 


INFECTION  OF  THE   UMBILICUS  85 

little  red  growths  which  reach  the  size  of  a  cherry  and 
situated  in  the  depths  of  the  umbilical  groove,  or  they 
rise  in  a  fungus-like  manner  above  its  sides,  and  always 
discharge  a  little  secretion  (see  Plate  18,  Fig.  2). 

Treatment. — Apply  caustic  ;  in  case  of  larger  growths 
tear  off  or  remove  with  a  pair  of  scissors.  [Treat  by 
solid  nitrate  of  silver  or,  if  large,  may  be  tied  off  with 
fine  silk. — Ed.] 

INFECTION  OF  THE  UMBILICUS 

The  umbilical  wound  may  become  infected  through  un- 
clean hands,  dressings,  instruments,  etc.  The  virus  in- 
fects either  the  umbilical  wound  itself  and  then  leads  to 
suppuration,  ulceration,  and  gangrene,  or  it  spreads  to  the 
surrounding  tissue  and  there  causes  a  phlegmonous  in- 
flammation (periomphalitis).  Then  again  it  may  travel 
through  the  Whartonian  jelly  in  the  walls  of  the  umbilical 
blood-vessels,  preferably  the  arteries,  where  it  sets  up 
severe  inflammation  (periarteritis).  The  phenomena  which 
arise  are  : 

Pyorrhea  of  the  Umbilicus. — Dried  secretion  collects  at 
the  reddened  entrance  of  the  umbilicus,  an  odorless  pus 
flows  forth  from  the  umbilical  wound,  and  a  suppurative 
granulation  occurs  at  the  base  of  the  wound.  There  are 
but  slight  constitutional  symptoms. 

Omphalitis  and  Periomphalitis. — These  are  marked  by 
swelling  and  reddening  of  the  umbilical  fold,  painful 
phlegmonous  swelling  and  bulging  forth  of  the  area  sur- 
rounding the  umbilicus,  and  the  appearance  of  enlarged 
lymph-vessels  upon  the  abdominal  wall.  This  condition 
terminates  in  spontaneous  healing,  abscess  formation,  gan- 
grene, and  fatal  peritonitis ;  under  certain  circumstances 
a  superficial  ulceration  of  the  umbilical  wall  results.  It 
is  always  accompanied  by  fever. 

Gangrene  of  the  Umbilicus. — The  swollen  or  phlegmon- 
ous area  turns  bluish  black,  the  discoloration  spreads 
rapidly,  and  the  tissue  softens  and  sloughs  off,  leaving  a 
discolored  and  foul-smelling  ulcer.  As  a  rule  the  proc- 
ess  spreads  over  the  peritoneum  and  the  symptoms  of 


86  DISEASES  OF  THE  NEWBORN 

peritonitis  develop.  The  patient  suffers  from  a)>dominal 
pain  and  distention  of  the  abdomen.  Death  follows  from 
sepsis  or  peritonitis. 

Umbilical  Arteries. — Local  phenomena  are  frequently 
absent.  The  patient  becomes  restless  and  develops  fever, 
intestinal  disturbances,  slight  icteric  coloring  of  the  skin, 
temporary  erythema  or  punctiforni  hemorrhages  in  the 
skin,  or  we  notice,  proceeding  from  within  outward,  the 
signs  of  a  septic  omphalitis.  Occasionally  it  is  possible, 
by  squeezing  from  below  upward,  to  force  pus  out  of  the 
umbilicus.  Bacteria  are  found  in  the  venous  blood.  The 
result  is  usually  death  after  a  few  days  from  peritonitis 
and  collapse. 

Anatomically  both  arteries  (the  vein  is  rarely  involved) 
are,  as  a  rule,  observed  to  be  thickened  and  discolored 
grayish  brown ;  the  lumena  are  filled  with  pus  or  semi- 
solid thrombi,  the  intima  is  softened  and  ulcerated,  and 
the  surrounding  tissue  is  infiltrated  and  discolored  green. 

Aside  from  these  disturbances  there  occur  in  nearly  all 
cases  ecchymoses  and  degenerative  changes  in  the  organs 
of  the  chest  and  abdomen,  pulmonary  infarcts  and  con- 
solidation, multiple  abscesses,  and  enlarged  spleen. 

Treatment  of  Infection  of  the  Umbilicus. — The  prophyl- 
axis consists  in  the  careful  observation  of  asepsis  in  treat- 
ing the  umbilicus,  especially  in  premature  births  and 
weakly  infants.  Mild  cases  are  cauterized  and  covered 
with  a  dry  antiseptic  powder.  In  severe  cases  make 
applications  of  aluminum  acetate  or  lysol  (^  to  ^  per  cent.) ; 
pus  should  be  removed  with  sterile  swabs.  In  case  of 
suppurative  phlegmon  make  warm  applications,  and  later 
incise.  Feeding  must  receive  careful  attention  and,  if 
possible,  the  child  should  receive  nourishment  from  its 
mother's  breast. 

SEPSIS  OF  THE   NEWBORN 

Etiology. — The  newborn  infant  shows  a  special  jiredis- 
position  to  septic  infections  because  of  the  undeveloped 
state  of  its  protective  mechanism  (skin,  mucous  membranes, 
lymph-nodes,  spleen).     The  causal  agents  of  infection  are 


SEPSIS  OF  THE  NEWBORN  87 

the  various  pus,  inflammatory,  and  putrefactive  bacteria. 
The  infection  occurs  before  or,  as  a  rule,  after  birth.  It 
develops  inutei'o  through  infected  liquor  amnii  or  by  trans- 
mission through  the  placenta.  After  birth  it  is  caused  by 
mioro-organisnis,  some  of  which  were  deposited  in  the 
body  itself  (auto-infection),  while  others  are  introduced 
from  without  (hetero-infection).  The  most  important 
points  of  entrance  for  the  infection  are  existing  inflam- 
mations or  loss  of  substance  of  the  umbilicus,  the  skin, 
the  oral  cavity,  the  lungs  (Fischl),  the  intestinal  canal, 
the  bladder  (Escherich,  Trumpp,  Epstein),  the  ears,  the 
eyes,  and,  finally,  apparently  uninjured  skin  and  mucous 
membrane.  Everything  which  comes  in  contact  with  the 
child's  body  in  the  course  of  its  care  may  serve  as  the 
source  of  infection,  including  the  hands,  bath-water, 
clothes,  sponges,  thermometer,  the  air,  incubator,  etc. 

Morbid  Anatomy. — If  the  toxin  has  entered  the  circu- 
lation and  caused  blood  intoxication,  we  find  parenchym- 
atous degeneration  of  the  internal  organs,  ecchymoses  in 
the  mucous  membranes,  and  thin  sterile  blood.  In  case 
of  blood  infection  degenerations  and  ecchymoses  are  also 
found,  together  with  multiple  abscesses,  pneumonia,  in- 
flammation of  the  serous  membranes,  ulceration  of  the 
mucous  membranes,  and  a  rapidly  developing  foul-smell- 
ing putrefaction. 

Symptoms. — There  is  no  regularity  in  the  symptom- 
atology, for,  on  the  contrary,  it  assumes  many  forms  and, 
indeed,  in  some  cases  is  quite  indefinite.  The  symptoms 
develop  immediately  or  in  a  few  days  after  birth,  and 
consist  in  a  loss  of  appetite,  high  fever,  a  choleraic 
diarrhea,  great  acceleration  of  pulse  and  respiration  rate, 
somnolence,  and  a  rapid  loss  of  strength.  Hemorrhages 
occur  in  tiie  dirty  icteric  and,  later,  cyanotic  skin.  Rest- 
lessness, tremor,  and  convulsions  are  noted.  The  high 
temperature  falls  to  or  below  normal,  and  in  many  cases 
symptoms  of  pneumonia,  peritonitis,  pleuritis,  meningitis, 
multiple  inflanmiation  of  joints,  embolism,  and  suppurative 
processes  of  the  skin  develop.  The  primary  focus  may  be 
apparently  absent  or  it  appears  as  a  suppurative,  phleg- 


88  DISEASES  OF  THE  NEWBORN 

monoiis,  ulcerated  or  gangrenous  process  of  one  of  the 
previously  mentioned  points  of  entrance.  The  course  is 
nearly  always  unfavorable ;  healing  in  very  mild  cases  or 
an  early  limitation  of  the  process  is  possible. 

Diagnosis. — This  is  not  easy  when  the  external  local- 
ization is  absent.  Designating  the  indefinite  and  unclear 
constitutional  condition  as  a  septic  one  is  made  easier  by 
the  ophthalmoscopic  finding  of  a  retinal  hemorrhage  or 
by  discovering  pus-germs  in  the  aspirated  venous  blood 
or  in  the  cerebrospinal  fluid. 

Treatment. — Prophylaxis  consists  in  insisting  upon 
thorough  cleanliness  in  the  care  of  the  pregnant  woman 
and  of  the  child,  especially  as  regards  the  linen,  the 
treatment  of  the  umbilicus,  the  bath,  the  thermometer, 
the  feeding  apparatus,  the  preparation  of  the  milk, 
hygiene  of  the  milk,  hygiene  of  the  room,  etc.  Rhagades 
or  injuries  occurring  during  birth  must  be  treated  anti- 
septically.  The  treatment  of  the  condition  itself  consists 
in  supporting  the  child's  strength,  the  administration  of 
mothers  or  hot  cows'  milk,  stimulants,  meat  broths, 
wine,  and  infusions  of  normal  salt.  To  combat  the  fever 
give  baths,  cold  pack,  and  quinin  (0.1  gm.).  Abscesses 
should  be  opened. 

BLENNORRHEA  NEONATORUM,  OPHTHALMIA 
NEONATORUM 

Blennorrhea  neonatorum  is  a  directly  transmissible 
inflammation  of  the  conjunctiva  of  newborn  infants 
caused  by  the  gonococcus  of  Neisser.  A  large  percent- 
age of  all  cases  of  total  blindness  is  due  to  this  condition. 
The  infection  occurs  either  immediately  after  birth, 
during  which  the  infected  genital  secretion  enters  the 
eyes,  or  later  through  infected  fingers  or  toilet  articles. 

Symptoms. — The  symptoms  develop  usually  within  the 
first  week,  but  in  later  infection  they  do  not  appear  until 
after  that  period.  The  eyelids  are  red  and  swollen  and 
a  bloody,  serous  secretion  flows  from  the  palpebral  fis- 
sure. The  swollen  lids  increase  in  size  during  the  next 
one  or  two  days  and  form,  especially  the  upper  lid,  a 


BLENNORRHEA   AND  OPHTHALMIA  NEONATORUM  89 

vaulted  eminence.  The  secretion  becomes  converted  into 
a  yellowish-red  pus.  The  conjunctiva  of  the  lids  is 
swollen  and  greatly  reddened.  When  the  lids  are 
inverted  the  transitional  folds  bulge  forward  as  tense, 
shiny  red  eminences.  The  conjunctiva  of  the  eyeball  is 
also  swollen  and  congested.  If  the  secretion  is  not  con- 
stantly removed  it  may  erode  the  cornea ;  in  that  case  a 
minute  speck  develops  in  the  middle  of  the  cornea,  which 
rapidly  enlarges,  turns  yellow,  and  its  superficial  portion 
undergoes  destruction.  The  resulting  suppurating  ulcer 
shows  a  great  tendency  to  spread  and  to  perforation. 
The  complications  of  this  infection  of  the  cornea  may  be 
central  macula,  anterior  capsular  cataract,  prolapse  of  the 
iris,  staphyloma,  or  panophthalmia.  After  a  number  of 
days  the  secretion  becomes  thicker,  yellowish  green,  and 
excreted  in  such  profuse  amounts  that  it  oozes  from  the 
palpebral  fissure  as  often  as  the  lids  are  opened.  In  the 
course  of  several  days  the  swelling  of  the  eye  diminishes, 
the  palpebral  conjunctiva  becomes  granular,  and  the 
secretion  gradually  lessens.  In  from  two  to  three  weeks 
the  conjunctiva  becomes  pale,  and  finally  nothing  is 
noticed  excepting  a  little  mucopurulent  secretion  at  the 
inner  canthus. 

Course  and  Prognosis, — The  total  duration  is  from  three 
to  five  weeks  or  even  longer.  The  later  the  disease 
develops  the  more  favorable  the  prognosis.  It  is  unfavor- 
able in  the  newborn  and  in  weakly  and  sickly  children. 
Even  in  infants  otherwise  healthy  the  prognosis  should 
always  be  guarded. 

Treatment. — As  a  prophylactic  measure  drop  a  2  per 
cent,  solution  of  nitrate  of  silver  in  both  eyes  after  birth 
(Crede).  It  is  usually  impracticable  to  protect  the 
healthy  eye  in  newborn  infants,  and  furthermore  both 
eyes  are  infected,  as  a  rule,  from  the  very  beginning.  In 
the  acute  stage  the  treatment  should  be  as  mild  as  possi- 
ble, in  ord«r  to  avoid  injuring  the  conjunctiva.  The  pus 
as  it  collects  should  be  regularly  and  as  frequently  as 
possible  removed  from  the  conjunctival  sac,  preferably 
by  rinsing  with  a  mild  solution  (.sodium  chlorid,  0.6  per 


90  DISEASES  OF  THE  NEWBORN 

PLATE  5 

Ophthalmoblennorrliea  of  the  Newborn. — (From  Haab's   Exter^uil 

Dissases  of  the  Eye.) 

cent  ;  boric  acid,  4  per  cent. ;  dilute  solution  of  potas- 
sium ])ermanganate).  It  is  allowed  to  flow  every  quarter 
or  half  hour  from  a  low  height  into  the  eye,  which  is 
held  open  with  the  fingers.  During  the  intervals  apply 
cool  compresses  made  from  one  of  the  above-mentioned 
solutions  (employ  no  ice  compresses,  which  may  increase 
the  damage  already  done  to  the  cornea).  Not  until  the 
swelling  has  lessened  and  pseudomembranes  no  longer 
develop  should  a  caustic  be  employed.  For  this  purpose 
use  a  3  per  cent,  silver  nitrate  solution,  which  should  be 
neutralized  later  with  normal  salt.  The  treatment  is  the 
same  when  the  cornea  is  involved.  When  perforation  is 
threatened  the  intra-ocular  pressure  may  be  relieved  l)y 
pilocarpin.  In  order  to  encourage  the  child  to  oj>en  its 
eyes  spontaneously  the  room  should  be  darkened  and  the 
eyes  slightly  cocainized.  In  cases  running  a  slow  course 
a  20  per  cent,  protargol  salve  should  be  employed  .(Sal- 
zer). 

TETANUS  NEONATORUM 

This  condition  consists  of  tonic  spasms  of  the  general 
musculature,  which  begin  in  the  muscles  of  mastication 
and  which  increase  in  severity  in  paroxysms.  These 
sj>asms  are  brought  about  by  the  toxin  of  the  bacillus  of 
tetanus. 

Etiology. — The  bacillus  of  tetanus,  which  is  quite 
prevalent  in  garden  earth  and  wood,  is  transmitted  to 
the  umbilical  wound  through  carelessness  in  the  care  of 
the  infant.  In  this  location,  from  which  oxygen  is 
excluded,  it  finds  conditions  favorable  to  its  development 
and  travels  from  there  into  the  body.  The  bacillus  may 
be  demonstrated   in  the  blood  or  in  the  umbilical  wound. 

Symptoms. — In  from  five  to  six  days  after  prodromal 
symptoms,  consisting  of  restlessness,  crying  out  in  sleep, 
and  tremor  of  the  jaw,  the  child  becomes  unable  to  take 
food  because  of  the  tonic  spasm  of  the  muscles  of  masti- 


I 


# 


^ 


\ 


-?, 


y 


TETANUS  NEONATORUM 


91 


cation.     Infants  fed  from  the  breast  show  the  first  indi- 
cation of  the  disease  by  biting  the   ni])ples,  and   when 


Fig.  24. — Tetauuh  neonatorum.  The  body  is  rigid  ;  tlie  expression  of 
the  face  and  tlie  position  of  the  arms  and  legs  are  characteristic.  (Esche- 
rich's  Clinic,  Vienna.) 

liquids  are  administered  they  flow  out  again.     The  cheeks 
become  hard  as  a  board.     Extension  of  the  spasm  to  the 


02  DISEASES  OF  THE  NEWBORN 

remaining  muscles  of  the  face,  the  muscles  of  the  neck, 
trunk,  and  extremities  presents  a  typic  picture.  The 
mouth  is  puckered  as  if  about  to  whistle  or  laugh,  the 
forehead  and  eyebrows  are  wrinkled,  the  eyes  are  closed, 
and  deep  furrows  extend  from  the  nose  to  the  lower  jaw. 
The  head  is  held  drawn  stiffly  backward,  the  neck  and 
back  are  in  a  state  of  opisthotonos,  the  arras  flexed  and 
pressed  against  the  body,  the  hands  clenched,  the  legs 
and  feet  extended,  and  the  abdomen  has  a  board-like 
hardness.  The  whole  body  of  the  child  when  lifted  feels 
like  a  stiff  wooden  doll.  Involvement  of  the  pharyngeal 
and  respiratory  muscles  causes  difficulty  in  swallowing 
and  breathing.  The  spasm  is  not  continuous,  but  lessens 
in  severity  to  a  certain  degree  for  a  short  period  of  time 
and  then  is  followed  by  a  convulsive  tremor  of  the  whole 
body.  The  intervals  of  quietude  last  at  the  beginning 
for  a  few  minutes,  but  later  only  for  a  few  seconds.  The 
spasms  are  exacerbated  by  external  mechanical  irritation, 
moving  the  body,  the  administration  of  food,  etc.  The 
whimpering  of  the  child  indicates  the  severity  of  the 
pain.  The  temperature  is  high  (40°  to  42°  C.  [104°- 
107.6°  F.] ),  especially  toward  the  end,  and  the  pulse  is 
small  and  weak.  The  child  dies  in  a  few  days  or,  at  the 
most,  in  a  week,  from  exhaustion  or  respiratory  failure. 
In  the  rare  cases  of  recovery  the  symptoms  gradually 
disappear  one  after  the  other. 

The  diagnosis  is  easily  made  when  the  disease  is  pro- 
nounced. Whenever  newborn  infants  refuse  nourishment 
the  musculature  of  mastication  should  be  examined. 

Treatment. — As  a  means  of  prophylaxis  the  mother  and 
child  should  receive  the  most  rigid  aseptic  treatment. 
The  results  from  the  use  of  Behring's  tetanus  antitoxin 
cannot  be  depended  upon  yet,  and  the  treatment  is  there- 
fore mainly  symptomatic.  Rest  is  absolutely  necessary; 
feeding  is  carried  on  by  means  of  a  tube  through  the  nose. 
Narcotics  and  repeated  chloroform  inhalations  are  neces- 
sary until  sleep  sets  in  (Heubner).  Chloral  should  be 
administered  by  means  of  enemata  twice  daily  in  0.5-gm. 
doses,  and  potassium  bromid  is  given  in  the  same  manner 


HELENA  NEONATORUM  93 

in  from  1.0- to  1.5-gm.  doses  daily.     Finally,  an  attempt 
should  be  made  with  the  antitoxin  as  soon  as  possible. 

MELEN A  NEONATORUM 

Melena  neonatorum  is  a  rare  disease  which  is  character- 
ized by  hemorrhages  into  the  gastro-intestinal  tract,  ac- 
companied by  bloody  stools  and  the  vomiting  of  blood. 
The  real  cause  is  unknown.  It  occurs  in  connection 
with  septic  processes,  Buhl's  disease,  syphilis,  and  trauma. 

Morbid  Anatomy. — The  stomach  and  intestines  are  filled 
with  black  blood,  the  source  of  which  are  minute  erosions 
and  round  ulcers  in  the  intestinal  and  gastric  walls,  or  a 
diifuse  hyperemia  of  the  mucous  membrane  (dia|)edesis), 
thrombosis,  or  bacterial  emboli.  The  remaining  organs 
are  anemic. 

Symptoms. — This  condition  has  a  sudden  onset  during 
the  first  few  days  of  life.  The  stools  contain  blackish 
blood-clots,  which  when  deposited  on  the  swaddling  cloths 
are  distinguished  from  the  meconium  by  a  dark  red  halo 
(see  Plate  37,  Fig.  1).  The  child  also  vomits  bloody 
masses,  but  not  in  all  cases.  Collapse  sets  in  early,  the 
extremities  become  cold,  the  pallor  increases,  and  the  fea- 
tures have  a  death-like  appeamnce.  The  child  may 
develop  the  symptoms  of  hydrocephalus  and  die  in  from 
one  to  two  days,  or  the  hemorrhage  ceases  and  recovery 
slowly  sets  in  ;  in  that  case  the  stools  continue  to  have  a 
tea-like  character  for  one  or  two  days.  Local  symptoms, 
pain,  etc.,  are  absent.  If  sepsis  develops  the  character- 
istic phenomena  of  that  condition  are  also  present.  The 
mortality  rate  is  50  to  60  per  cent. 

Diagnosis. — The  characteristic  collapse  and  the  anemia 
fail  to  appear  in  we/t'Wrt  spuria,  which  consists  in  vomiting 
and  passing  per  rectum  blood  that  has  been  swallowed 
from  the  mother's  nipple  or  from  the  nose  and  pharynx 
of  the  child  itself. 

Treatment. — Inject  subcutaneously  loccm.  of  a  2  to  5  per 
cent.  (Merck's)  sohition  of  gelatin  (Zuppinger).  Give  1 
drop  of  liquor  ferri  sesquioxid  in  1  spoonful  of  gruel.  In 
every  case  an  ice-bag  should  be  applied  to  the  abdomen 


94  DISEASES  OF  THE  NEWBORN    . 

and  heat  supplied  to  the  rest  of  the  body.  [The  reports 
from  gelatin  injections  are  not  uniformly  favorable.  The 
editor  has  observed  sym])toms  of  collapse  in  children  who 
have  received  these  gelatin  injections.  He  believes  the 
gelatin  should  be  administered  by  mouth.  Other  medic- 
inal treatment  should  consist  of  the  administration  of  1- 
or  2-drop  doses  of  adrenalin  solution. — Ed.] 

ACUTE  HEMOGLOBINURIA  OF  THE  NEWBORN 

(  WinckePs  Disease) 

Acute  hemoglobinuria  of  the  newborn  is,  on  the  whole, 
a  rare  diseassc,  occurringendemieally  and  sporadically,  and 
is  associated  with  cyanosis,  icterus,  and  hemorrhages  from 
the  various  organs.  Death  occurs,  as  a  rule,  in  thirty-two 
hours.  Anatomically  we  find  swelling  of  Pyer's  patches 
and  of  the  mesenteric  glands,  dark  red  discoloration  of 
the  kidneys  (the  pyramids  of  which  show  dark  hemo- 
globin striation),  and  fatty  degeneration  of  the  liver  and 
other  organs.  The  urine  contains  hemoglobin,  casts, 
bacteria,  and  detritus.     Treatment  is  useless. 

BLOOD-TUMOR  OF  THE  HEAD.    CEPHALHEMATOMA 

A  cephalhematoma  is  a  collection  of  blood  between  the 
cranial  bones  and  the  periosteum,  either  external  (between 
the  periosteum  and  the  skull)  or  internal  (between  the  dura 
and  the  skull) ;  as  a  rule  it  is  a  combination  of  both 
varieties.  It  is  caused  by  laceration  of  blood-vessels  and 
loosening  of  the  periosteum  during  birth. 

The  external  cephalhematoma  appears  as  a  fluctuating 
and  elastic  growth,  varying  in  size  from  that  of  a  hazel- 
nut to  that  of  an  apple,  which  is  usually  situated  over  one 
of  the  parietal  bones.  It  is  joined  to  the  edges  of  a  bone 
and  never  extends  over  a  suture  or  a  fontanel.  The  skin 
is  movable  and  somewhat  bluish.  After  several  days  a 
wall  is  formed  at  the  periphery  of  the  growth,  which  is 
at  first  soft,  but  later  as  hard  as  bone.  This  wall  is  caused 
by  ossification  of  the  loosened  periosteum.     The  growth 


MASTITIS  NEONATORUM  95 

increases  in  size  during  the  first  four  days,  it  then  remains 
stationary,  and  after  the  second  week  grows  smaller.  On 
palpation,  crepitation  is  felt  because  of  the  deposition  of 
bony  substance  in  the  upper  layer  of  the  tumor.  The 
swelling  disappears  in  about  twelve  weeks  and  the  prog- 
nosis is  favorable. 

Diagnosis. — A  cephalhematoma  is  to  be  distinguished 
from  the  edema  of  the  head  occurring  during  labor,  which 
is  doughy  in  consistency  and  extends  over  the  sutures,  by 
its  distinct  limitation  to  one  bone,  growth  after  birth, 
fluctuation,  and  bony  wall.  The  absence  of  inflammatory 
and  constitutional  symptoms  differentiates  it  from  abscesses. 
A  cephalhematoma  may  be  mistaken  for  cerebral  hernia, 
but  this  error  may  be  avoided  by  remembering  that  a 
ceiv'bral  hernia  occurs  between  the  bones,  that  it  is  redu- 
cible, pulsates,  and  is  enlarged  by  crying  and  coughing. 

Treatment. — This  may  be  expectant  and  consists  in 
applying  a  simple  protecting  bandage,  followed  in  eight 
days  by  aseptic  puncture  and  aspiration,  or  making  an  in- 
cision and  applying  a  light  pressuredressing(von  Winckel). 
[The  expectant  plan  of  treatment  is  all  that  is  required, 
as  the  condition  tends  to  spontaneous  recovery. — Ed.] 

MASTITIS  NEONATORUM 

The  physiologic  swelling  of  the  colostrum-secreting 
mammary  glands  of  the  newborn  may  lead,  through  in- 
fection from  without,  to  inflammation.  It  is  caused  by 
unnecessary  squeezing  of  the  gland  with  unclean  fingers. 
When  the  abscess,  which  is  usually  one  sided,  is  not 
incised  at  the  proper  time,  it  discharges  externally  and 
causes  permanent  disturbance  of  individual  portions  of 
the  gland. 

Treatment. — Prophylaxis  consists  in  forbidding  the 
squeezing  out  of  the  milk  in  the  breasts  of  the  newborn. 
If  inflammation  is  present  ajiply  altnninum  acetate  ;  in 
case  of  an  abscess  ap]>ly  poultices.  [Wet  dressings  of 
boric  acid  or  hot  boric-acid  solutions  may  be  used. — Ed.] 
Then  make  radial  incision  and  dress  with  aluminum 
acetate. 


i>6  MALFORMATIONS 

MALFORMATIONS 

Double  monstrosities  are  of  no  practical  interest.  Of 
the  single  monsters  only  the  most  important  will  be  con- 
sidered here.  Malformations  arise,  as  a  rule,  from  ex- 
ternal or  internal  causes.  The  latter  are  chiefly  typic 
forms,  which  are  due  to  heredity  or  primary  pathologic 
variations  in  the  embryo.  The  former  are  due  to  any 
form  of  external  injury  which  disturbs  the  embryonal 
rudiment  in  the  course  of  its  development ;  the  atypic 
types  are  usually  of  this  class. 

MALFORMATION  FROM  ARRESTED  DEVELOPMENT, 
MONSTRA  PER  DEFECTUM 

( Incomplete  Closure  of  the  Cerebrospiiwi  Canal) 

Anomalous  fontanels  occur  as  osseous  lacunse  in  the 
mesial  plane  of  the  vault  of  the  cranium.  They  are  most 
frequently  found  in  the  region  of  the  glabella  and  in  the 
middle  of  the  sagittal  suture. 

Dermoid  spaces  within  the  cranial  bones  themselves  are 
most  common  in  the  parietal  bones.  The  prognosis  is 
good.  If  they  persist  until  the  walking  period,  the  child 
must  wear  a  cap  with  leather  or  metal  plates. 

The  formation  of  clefts  or  fissures  in  the  region  of  the 
cerebrospinal  canal  is  due,  according  to  von  Reckling- 
hausen, to  primary  agenesis  and  hypoplasia  of  the  em- 
bryonal medullary  ridge.  If  the  arrest  of  the  develoj)- 
ment  occurs  in  the  cranial  portion  of  the  canal  it  results 
in  fissure  formation  of  the  cranium. 

Cranioschisis  or  acrania  is  a  congenital  defect  of  the 
skull,  which  is  accompanied  either  by  total  absence  of 
the  brain — total  anencephalus — or  by  partial  absence — 
partial  anencephalus.  The  contents  of  the  skull  fre- 
quently protrude  through  the  fissure,  which  acts  as  the 
orifice  of  a  hernial  sac.  If  only  the  cerebral  membranes 
and  fluids  enter  the  sac  the  condition  is  called  a  menin- 
gocele, but  if  it  also  holds  cerebral  substance,  an  en- 
cephalocele  is  formed. 


MALFORMATION  FttOM  ARRESTED  DEVELOPMENT    97 

An  encophalocele  occurs  in  various  degrees,  that  is, 
small  and  large,  and  can  be  detected  when  it  is  small  only 
by  a  very  careful  examination.  The  hernial  sac  is  com- 
posed of  either  the  dura  and  arachnoid,  or  both  of  these 
together  with  the  soft  cranial  plates,  or  the  latter  alone. 


Fig.  25. — Acrania,  partial  aneucephalus  (insufficient  brain),  encephalo- 

cele. 


The  swelling  is  elastic,  it  communicates  with  the  in- 
terior of  the  skull  and  is  situated  between  the  bones  (a 
cephalhematoma  lies  directly  upon  the  bones)  ;  its  presence 
may  finally  be  decided  by  a  cautious  puncture.  Cerebral 
hernias  are  most  frequently  found  in  the  occiput,  less  often 


98 


MALFORMATIONS 


in  the  frontal  region  and  at  the  base  of  the  skull.  Partial 
hernias  of  moderate  degree  are  accompanied  by  pain  and 
also   convulsions  when   the   swelling   is   pressed    upon ; 


Fio.  20. — Crauioschisis  aud  eiice})halocele  of  mild  grade;  double  club- 
foot. 


various  nervous  symptoms  also  occur.  Characteristic  of 
the  severe  ca.ses  are  the  bulging  eyes  and  the  whole  ex- 
pression of  the  face — toad's  head.     Only  the  very  mild 


MALFORMATION  FROM  ARRESTED  DEVELOPMENT    99 

cases  continue  to  live  and  may  heal  spontaneously.  The 
treatment  consists  in  wearing  a  protecting  cap  or  an  opera- 
tion. In  most  cases  this  condition  is  associated  with 
other  malformations,  such  as  hare-lip,  club-foot,  etc. 


Fici.  27. — Sacral  spina  bifida,     (von  Eanke's  Cliuic,  Munich.) 


RacMschisis  is  partial  or  complete  failure  in  closure  of 
tiio  s{)inal  canal.  When  the  cranial  cavity  is  also  ex- 
posed the  condition  is  called  craniorrachischisis.  Of  prac- 
tical importance  are  the  partial  fissure  formations,  which 
lead  to  a  hernia  of  the  spinal  cord — spina  bifida.  Three 
varieties  are  distinguished  : 


100 


MALFORMATIONS 


Spinal  Meningocele. — This  heruia  consists  of  a  pro- 
truded portion  of  the  pia,  which  is  filled  with  cerebro- 
spinal fluid. 


FiQ.  28. — Cervical  spina  bitida.     (Escherich's  Clinic,  Vienna.) 


Myelomeningocele,  in  which  the  hernial  sac  contains  also 
the  nerve  roots  or  a  portion  of  the  spinal  cord. 


MALFORMATION  FEOM  ARRESTED  DEVELOPMENT  101 


Fig  29.— Hare-lip.  associated  with  encephaloccle,  left  perodactylus,  and 
club-foot.     Infant  five  days  old,  which  died  in  eight  days. 


102 


MALFORMATIONS 


Myelocystocele,  which  is  a  protrusion  of  the  pia  due  to 
a  cystic  enlargement  of  the  central  canal. 

Spina  bifida  is  an  elastic,  fluctuating,  usually  elongated 
tumor  in  the  lumbar,  sacral,  and  rarely  in  the  cervical 
portion  of  the  spine.  It  reaches  the  size  of  a  child's  head 
and  may  be  made  smaller  by  pressure  (stretching  of  the 
fontanels  and  eventually  convulsions). 


Fig.  30. — Double  cleft  of  the  lip,  jaw,  and  palate,  with  a  rudimentary 
intermaxillary  bone,  which  is  a  continuation  of  the  front;il  process. 
Preparation  of  the  Munich  Pathologic  Institute.) 


The  skin  over  the  swelling  is  normal  or  thin  and  livid. 
The  second  and  third  forms  are  usually  associated  with 
paralytic  phenomena  in  the  region  supplied  by  the  in- 
volved spinal  nerves.  The  small  spinal  bifidas  may 
undergo  spontaneous  cure,  but  the  ])rognosis  for  the  larger 
ones,  especially  the  second  and  third  forms,  is  hojieless. 


MALFORMATION  FROM  ARRESTED  DEVELOPMENT  103 

The  treatment  involves  the  use  of*  protective  appliances, 
puiK'tiiro,  or  operation. 

Facial  Defects. — The  face  is  formed  by  the  union  of  the 
])aired  processes  from  the  visceral  and  branchial  arches 
with  the  frontal  process,  which  is  single.  Disturbances 
in  this  union  lead  Lo  a  more  or  less  marked  deformity  of 
the  face. 


Fia.  31. — Double  fissure  of  the  jaw  and  the  palate,  with  a  rudimentary 
iiiteriuiixillarv  Ixmo  prqjectinjt  from  the  frontal  process.  (Preparation  of 
the  Munich  Pathohigic  Institute.) 

The  lowest  degree  of  deformity  is  represented  by  an 
indentation  or  sear-like  line  in  the  up])er  lip  or  a  forked 
division  of  the  uvula.  A  stage  further  is  the  hare-lip 
(labium  le])orinuml,  a  lateral  fissure  of  the  upper  lip, 
which  is  frequently  combined  with  a  cleft  alveolar  proo- 


104 


MALFORMATIONS 


I 


Fig.   32. — Microceiihalus,    iuvolviug    mainly   the    skull.      (Escherich's 
Clinic,  Viouua.) 

ess.     Next  comes  the  clefl  pahite  (palatum  fissiim),  which 
consists  of  a  fissure  of  the  hard  palate,  and  is  usually 


MALFORMATION  FROM  ARRESTED  DEVELOPMENT  105 

associated  with  hare-lip  and  occurs  either  on  one  or  on 
both  sides.  At  times  the  intermaxillary  bone  rests  as  a 
nodular  process  in  the  median  line.  These  deformities 
result  in  difficulty  in  sucking,  varying  according  to  the 
depth  of  the  cleft ;  in  case  of  defects  of  the  alveolar 
process  and  the  hard  palate,  sucking  is  impossible,  and 
feeding  must  be  performed  with  a  spoon  while  the  head 
is  held  up.  The  treatment  is  exclusively  operative. 
[Owing  to  the  fact  that  infants  bear  operations  poorly, 
they  should  be  deferred  until  at  least  the  third  month  of 
life.— Ed.] 

Microcephalus  is  a  condition  in  which  a  skull  is  abnor- 
mally small  in  all  dimensions  or  only  in  the  cranial  por- 
tion. It  follows  premature  synostosis  of  the  cranial 
bones  or  arrest  in  the  growth  of  the  brain  because  of 
encephalitic  and  meningitic  processes.  It  is  accompanied 
by  a  flat  receding  forehead,  pointed  head,  a  low  cranium, 
and  protrusion  of  the  jaws  {prognathism).  As  a  rule  the 
patient  is  an  imbecile,  varying  in  degree  from  the  lowest 
to  the  highest  grade. 

Congenital  Cervical  Fistula. — This  follows  failure  in 
union  of  tlie  second  branchial  arch  (Striibing).  The  ex- 
ternal orifice  of  this  fistula  lies  between  the  two  sterno- 
mastoid  muscles  near  the  clavicle,  and  ends  either  blindly 
or  opens  in  the  pharynx.  It  secretes  a- mucoid  fluid.  The 
treatment  should  consist  in  an  attempt  at  total  extirpa- 
tion. 

Congenital  Hygroma  of  the  Neck. — This  is  a  serous  cyst, 
possessing  multiple  compartments,  which  lies  beneath  the 
inferior  maxilla  or  over  the  clavick.  It  penetrates  deeply 
into  the  connective  tissue  of  the  neck  and  mediastinum 
and  may  grow  to  a  considerable  size.  The  treatment  in- 
volves extirpation  or  incision,  followed  by  iodoform 
tampons. 

Hypertrophy  of  the  Tongue,  or  Macroglossia.^The  tongue 
may  be  congcnitally  enlarged  because  of  an  overgrowth  of 
interstitial  tissue  or  of  the  muscular  tissue  itself.  This 
enlargement  causes  the  tongue  to  protrude  (prolapsus 
linguae)  and  to  interfere  with  speech  and  the  ingestion  of 


1 06  MALFORMA  TIO^S 

food.  In  mild  cases  the  tongue  is  treated  by  applying 
alum  or  by  painting  it  with  a  weak  solution  of  iodin;  in 
severe  cases  excise  a  wedge-shaped  section  or  cauterize, 

Ranula. — This  is  a  tumor  on  the  floor  of  the  mouth, 
due  to  cystic  degeneration  of  the  sublingual  gland  or  its 
excretory  ducts.  Its  walls  are  thin  and  transparent ;  it 
contains  liquid  and  grows  as  large  as  a  pea  or  a  walnut. 
It  interferes  to  a  certain  extent  with  swallowing  by  dis- 
tention, and  thus  elevating  the  tongue.  The  treatment 
consists  in  excision  of  the  anterior  wall  and  in  cauteriz- 
ing the  stump. 


;-«^i«* 


Fig.  33. — Ranula.  The  growth  lies  in  the  middle  of  the  mouth,  and 
seems  to  be  divided  into  two  parts  by  the  constriction  of  the  frenum. 
(From  Granwald,  Diseases  of  the  Oral  Cavity.) 

Abnormal  Attachment  of  the  Tongue. — The  lingual 
bands  may  be  too  short  or  inserted  too  far  forward 
(ankyloglossia),  on  account  of  which  there  is  difficulty  in 
sucking  and  speaking. 

Treatment  is  less  often  indicated  than  is  expected  by 
the  mothers  and  mid  wives.  The  frenum  is  severed  while 
the  tongue  is  held  upward  by  the  thumb  and  index-finger 
of  the  left  hand,  or  by  means  of  a  tongue-tie.  When  the 
lower  surface  of  the  tongue   is    congenitally  grown    to 


MALFORMATION  FROM  ARRESTED  DEVELOPMENT  107 

tho  floor  of  the  mouth,  it  must  be  loosened  either  by 
blunt  dissection  or  by  incising,  and  followed  by  cauter- 
ization. Fissures  of  the  sternum  as  well  as  defects  of 
the  ribs  and  clavicle  are  practically  of  little  importance. 

Hernia  of  the  Umbilical  Cord. — (See  p.  81.) 

Ectopia  of  the  Bladder,  Prolapsus  Vesicae  or  Inversio 
Vesicae. — This  is  a  defect  of  the  anterior  wall  of  the  ab- 
domen and  bladder  through  which  the  posterior  wall  is 
seen.  Soon  after  birth  the  abdominal  pressure  causes 
the  posterior  vesical  wall  to  protrude  as  a  red,  shiny  tumor 
the  size  of  a  walnut.  The  flow  of  the  urine  from  the 
orifices  of  the  ureters  may  be  plainly  seen.  The  urine, 
which  has  a  strong  odor  and  has  undergone  ammoniacal 
changes,  causes  excoriations  and  eczema  of  the  surround- 
ing skin.  These  children,  who  usually  possess  other  mal- 
formations, as  a  rule,  soon  die,  yet  if  the  defect  is  a  mild 
one  the  subject  may  continue  to  liv^e.  The  treatment  is 
surgical. 

Meckel's  Diverticulum, — The  omphalomesenteric  duct, 
which  in  the  embryo  forms  a  communication  between  the 
mid-gut  and  the  umbilical  vesicle,  may  persist  as  a  blind 
pouch  of  the  intestine  lying  at  right  angles  to  the  wall 
of  the  lower  portion  of  the  ileum.  This  glove-finger-like 
sac  possesses  the  same  structure  as  the  ileum  and  either 
hangs  freely  in  the  abdominal  cavity  (genuine  divertic- 
ulum) or  is  fastened  at  its  apex  to  the  umbilicus.  It  forms 
within  the  umbilical  ring  a  small  prominent  growth  (open 
diverticulum,  see  Fig.  34),  which  at  the  time  of,  or  after 
the  umbilical  cord  has  dropped  off,  becomes  patulous,  and 
thus  leads  to  a  fistula  between  the  umbilicus  and  the  in- 
testine. 

Atresia  of  the  Anus. — Simple  atresia  of  the  anus  is  due  to 
persistence  of  tho  anal  membrane,  which  separates  the 
l)lind  end  of  the  rectum  (proctodeum)  and  the  invagina- 
tion of  the  skin  from  without.  If  the  l)lind  end  of  the 
rectum  opens  in  another  direction,  into  the  bladder,  the 
urethra,  or  vagina,  there  results  either  atresia  ani  vesicalis, 
urethralis,  or  vaginalis.  Excepting  the  last  form,  in 
which  under  certain  circumstances  defecation  may  be  per- 


108  MALFORMATIONS 

FIGURE  34 

Meckel's  Diverticulum.— The  omphalomesenteric  duct  protrudes  from 
the  umbilical  riug  as  a  round  growth  (open  diverticulum),  and  shows  a 
small  opening  which  developed  when  the  umbilical  cord  dropped  off. 
This  opening  communicates  with  the  intestines  (fistula  intestini  umbil- 
icalis).  There  is  also  malformation  of  the  right  hand.  (Escherich's 
Clinic,  Vienna.) 


formed,  the  patient  can  only  live  after  the  malformation 
has  been  corrected  by  an  operation. 

DEFORMITIES  OF  THE  EXTREMITIES 

The  many  different  types  of  deformity  or  complete 
absence  of  the  extremities  are  of  more  theoretic  than 
practical  interest.  (For  chondrodystrophia  and  osteogene- 
sis imperfecta  as  a  cause  of  micromyelia,  see  p.  132.) 

The  most  important  defect  of  individual  bones  is  the 
congenital  malformation  of  the  radius.  This  may  be 
completely  absent  or  be  defective  only  at  one  end.  If  the 
lower  end  is  absent,  it  may  be  substituted  by  a  vicarious 
enlargement  of  the  end  of  the  ulna.  The  results  of  this 
defect  are :  Strong  radial  flexion  of  the  hand ;  the  long 
axis  of  the  hand  forms  with  that  of  the  forearm  an  acute 
angle ;  the  radial  border  of  the  hand  is  easily  placed 
against  the  radial  surface  of  the  forearm,  and  the  hand  is 
rotated  on  its  long  axis  (club-hand).  The  treatment  con- 
sists in  an  attempt  to  secure  a  useful  position  of  the  arm 
and  hand  by  means  of  splints  and  fixation  bandages. 

Polydactylism,  or  Abnormal  Number  of  Fingers. — Super- 
numerary fingers  are  attached  either  to  one  side  of 
the  hand  or  placed  between  the  other  fingers.  If  the 
supernumerary  finger  is  well  developed  it  shares  either  a 
metacarpal  bone  with  a  neighboring  finger  or  it  possesses 
its  own,  and,  indeed,  such  a  finger  may  have  a  separate 
carpal  bone.  The  latter  type  is  to  be  regarded  as  retro- 
gression to  the  heptadactyle  prototype  of  the  mammalian 
hand.     The  treatment  consists  in  removal  by  operation. 

Syndactylism. — This  consists  of  union  between  two  or 
more  fingers  by  means  of  a  membranous  growth.  It  may 
be  total  or  partial  ;  the  bones  are  usually  separated.    The 


Fig.  34. 


110 


MALFORMATIONS 


Fig.  35.  — Intra-uterine  amputation  of  the  left  forearm  by  an  amniotic 
band.     (Escherich's  Clinic,  Vienna.) 


DEFORMITIES  OF  THE  EXTREMITIES 


111 


Fiu.iiG.-C.nyonitiil  defect  of  the  left  radius.  Stroug  r.nlLil  flexion 
of  the  hand  and  rotation  of  the  same  on  its  long  axis — club-hand.  (Esch- 
erich's  Clinic,  Vienna.) 

treatment   is   surgical  and  should  take  place  during  the 
first  years  of  life. 


112  MALFORMATIONS 

Manus  vara  is  a  congenital  contraction  of  the  wrist- 
joint.  The  hand  is  held  in  a  position  of  strong  volar 
and  ulnar  flexion  ;  when  the  wrist  is  extended  the  fingers 
are  bent.  It,  like  club-foot,  is  due  to  intra-utorine  dis- 
turbance, and  is  distinguished  from  club-hand  by  the 
absence  of  a  radial  defect. 

Pes  varus,  or  congenital  club-foot,  depends  upon  an 
incorrect  position  of  the  foot,  which  is  held  supinated 
under  abnormal  circumstances  (Bessel-Hagen).  The 
cause  is  partly  due  to  the  germinal  layer  and  partly  to 
intra-uterine  pressure  and  disturbance.  The  outer  edge 
of  the  foot  is  depressed  and  the  inner  edge  is  elevated. 
The  sole  is  drawn  inward  ;  and  the  condition  is  nearly 
always  combined  with  excessive  plantar  flexion  and  adduc- 
tion of  the  toes  (pes  equino varus).  Proper  orthopedic 
procedures  may  correct  this  deformity  and  restore  com- 
plete function  to  the  part. 

Pes  equinus,  pes  valgus  (flat-foot),  and  pes  calcaneus,  like 
genu  valgum  and  varum  (knock-knee  and  bow-leg),  are, 
as  a  rule,  acquired  during  life. 

Congenital  Luxation  of  the  Hip-joint. — According  to 
Lorenz  this  is  the  most  frequent  congenital  deformity. 
Three  grades  of  luxation  are  distinguished  (F.  Lange) : 

Supracotyloid  luxation,  in  which  the  head  rests  above 
the  socket,  and  can  be  felt  anteriorly  in  the  groin  on  ex- 
tending and  flexing  the  leg.  It  cannot  be  felt  in  the 
external  iliac  fossa  by  the  Malgaigne  method  (adduction 
and  flexion). 

The  supracotyloid  and  iliac  luxation,  in  which  the 
head  of  the  femur,  when  the  leg  is  extended,  is  felt 
anteriorly  in  the  groin,  and  when  flexed,  posteriorly  in  the 
external  iliac  fossa. 

The  iliac  luxation,  in  which  the  malposition  of  the 
head  is  permanent.  The  latter  is  palpable  in  the  external 
iliac  fossa,  both  on  extension  and  flexion  of  the  leg. 
Distinct  symptoms  usually  show  themselves  first  when 
the  child  begins  to  walk.  A  waddling  gait  is  caused  by 
the  shortening  of  the  leg,  the  loose  capsular  ligaments, 
and  the  insufficient  stretching  of   the   gluteal    muscles. 


DEFORMITIES  OF  THE  EXTREMITIES  113 

The  pelvis  sinks  downward  and  scoliosis  develops.  In 
case  of  double  luxation  the  child  develops  a  duck-like, 
waddling  gait,  pronounced  lumbar  lordosis,  and  protrusion 
of  the  abdomen.  Since  these  phenomena  are  also  possible 
in  rachitic  deformity  of  the  neck  of  the  femur  (coxa  vara), 


Fig.  37. — Coujiciiital  supracotyloid  luxation  of  the  left  femur.  Radio- 
gram, taken  in  dorsal  posture,  of  girl  two  and  a  half  years  old.  The 
head  of  the  femur  lies  at  the  upper  border  of  the  socket.  (From  Luning 
and  Schulthess,  Atlas  of  Orthopedic  Surgery.) 

the  diagnosis  should  be  made  in  every  ca.se  by  means  of  a 
Rontgon  photograph.  Orthopedic  treatment  (girdle,  blood- 
less reduction)  offers  permanent  cure,  provided  it  is  in- 
stituted before  the  fifth  year  of  life. 


CONSTITUTIONAL   DISEASES 

RACHITIS 

Rachitis  is  a  condition  characterized  by  an  insufficient 
deposit  of  calcium  salts  in  the  bony  tissue.  As  direct 
results  of  this  insufficiency  of  lime  are  an  abnormal  degree 
of  softness,  abnormal  hypertrophy,  and  a  lack  of  lotigi- 
tudinal  growth  of  the  bones,  while  the  weight  of  the 
skeleton  as  well  as  the  tension  of  the  muscles  cause  a  large 
variety  of  deformities  of  the  soft  and  flexible  bones. 

Rachitis  occurs  usually  between  the  ages  of  one  and 
two  years,  yet  it  may  develop  in  very  young  infants  or 
even  at  birth.  As  a  rule  rachitis  of  the  skull  apjjears 
during  the  earlier  periods  of  life. 

SYMPTOMS 

The  Skull. — The  large  fontanel  is  more  patulous  than 
it  should  be  at  that  age,  and  remains  open  until  the  second 
or  third  year  (normally  it  closes  in  from  the  twelfth  to  the 
fourteenth  month).  Its  edges  are  soft,  and  being  thick- 
ened they  rise  above  the  surface  of  the  scalp.  The  small 
fontanel,  which  should  be  closed  at  birth,  is  still  open  and 
its  edges  are  likewise  soft.  The  portions  of  the  temporal 
and  occipital  bones  adjacent  to  it  show  isolated  and  soft- 
ened thin  areas  called  craniotahes^  which  give  a  parclunent- 
Jike  crepitus  on  pressure.  The  sutures  gape.  Swelling 
of  the  frontal  and  occipital  tuberosities  give  the  skull  a 
square  appearance — caput  qiiadratum.  As  a  result  the 
whole  head  seems  enlarged  and  may  sometimes  be  mis- 
taken for  hydrocephalus. 

'  The  examination  for  craniotabes  is  performed  with  the  thinl  and 
fourth  fingers  of  both  handi^,  which  are  placed  flat  upon  tlie  sides  of 
the  skull. 

114 


SYMPTOMS 


115 


Fig.  38.— Craniotabes.  Eachitic  decakitication  of  the  right  paretal 
bone ;  gaping  sagittal  and  lanibdoidal  sutures.  One-year-old  child. 
(Preparation  in  the  Pathologic  Institute  of  Munich.) 


Fig.  39. — Rachitic  teeth.  Boy  nine  and  a  half  years  old.  The  teeth  are 
poorly  developed,  considerably  eroded  and  grooved.  Their  position  is  very 
irregular  ;  the  lower  incisors  occupy  a  frontal  position  ( not  in  the  arch  of 
the  jaw)  and  the  inferior  maxilla  makes  an  angular  turn  at  the  canine 
teeth. 


116 


RACHITIS 


Fig.  40. — Rachitic  boy  of  three  years.  A  large  and  somewhat  angular 
head.  The  typic  posture  of  a  rachitic  child,  with  the  amis  supported 
at  his  side.  Curvature  of  the  clavicles  and  the  spine  (see  Fig.  41)  causes 
the  neck  to  appear  short.  Contraction  of  the  lateral  diameter  of  the 
thorax ;  abdomen  protrudes ;  curvature  of  the  bones  of  the  forearm. 

The  superior  maxilla  is  lengthened  in  the  sagittal 
diameter,  on  account  of  whicli  its  middle  [)ortion  is  more 
prominent.  The  inferior  maxilla  makes  an  angular  turn 
in  the  neighborhood  of  the   second  incisor  teeth,  and 


SYMPTOMS 


117 


therefore  appears  to  be  flattened  in  front.  The  teeth, 
whose  eruption  is  dehiycd  and  occurs  at  irregular  inter- 
vals, are  considerably  displaced  on  account  of  deformity 
of  the  alveoli  in  which  they  are  inserted.  Their  occlud- 
ing surfaces  do  not  coincide,  the  canine  teeth  meeting  in 
a  sagittal  line  and  the  lower  incisors  in  a  frontal  line. 


Fig.  11.  Kachitic  boy  (liitcral  view  of  Fig.  40).  Rachitic  rounded 
kyi)liosis  (perfectly  compensated  when  lying  upon  the  abdomen)  ;  swell- 
ing of  the  epiphyses  of  the  bones  of  the  forearms  and  at  the  junctiou  of 
the  cartilaginous  with  the  bony  portions  of  the  ribs. 

The  surface  of  the  teeth  is  usually  prematurely  dis- 
colored a  dirty  yellow,  and  presents  fossae  in  close  prox- 
imity to  the  gums.  Later  they  are  striped,  grooved, 
notched,  undergo  decay,  and  crumble  away. 


118 


RACHITIS 


Fig.  42. — Extinel  racliitis.  A  six-jear-oUlgirl,  showing  decided  curva- 
tures of  the  bones,  which  have  now  become  hard.  (Escherich's  Clinic, 
Vienna.) 


SYMPTOMS 


119 


Thorax. — Either  all  or  only  individual  bones  are  en- 
larged at  their  cartilaginous  extremities,  and  in  some 
cases  plainly  knobbed — '•  rachitic  rosary." 

The  weight  of  the  arms,  the  traction  of  the  diaphragm, 
and  the  atmospheric  pressure  cause  flattening  and  retrac- 
tion of  the  lateral  thoracic  walls,  a  diminution  of  the 
transverse  diameter,  and  an  increase  of  the  sagittal 
diameter  (rachitic  chicken-breast).  The  lower  portion  of 
the  thorax  over  the  liver,  spleen,  and  stomach  bulges 
outward. 


^  '^S^iA^.ivietasi,.' 


Fig.  43. — Severe  rachitis ;  osteomalacic  form  with  enormous  deformities 
of  all  extremities.     (Escherich's  Clinic,  Vienna.) 

Vertebrae. — Posterior  curvature  of  the  lower  portion  of 
the  thoracic  spine  is  one  of  the  most  frequent  phenomena. 
This  rachitic  form  of  kyphosis,  contrary  to  the  type  met 
with  in  spondylitis  (Pott's  disease),  disappears  when  the 
subject  lies  on  its  stomach  (provided  ossification  has  not 
set  in)  and  is  not  painful.  A  vicarious  lumbar  lordosis 
is  frequently  present.  The  other  forms  of  scolioses  do 
not  develop,  as  a  rule,  until  later  in  life,  and  from  other 
causes. 

Pelvis. — The  weight  of  the  body  presses  the  iliac  bones 
outward,  the  sacrum  and  promontory  forward,  and  elevates 
the  OS  pubis.  As  a  consequence  the  true  conjugate  diam- 
eter is  shortened  and  the  transverse  diameter  is  increased. 

Extremities. — The  changes  in  the  extremities,  as  a  rule, 
occur  later  in  the  disease  than  those  of  the  skull.  They 
consist  of  a  nodular  swelling  of  the  lower  epiphyses  of 


120  RACHITIS 

the  radius,  ulna,  tibia  and  fibula,  and,  more  rarely,  the 
humerus  and  femur.  Furthermore,  traction  of  the  mus- 
cles and  their  weight  cause  curvatures  or  even  greenstick 
fractures  of  the  shafts  of  these  bones  ;  as  a  rule  the  radius 
and  ulna  are  bent  convexly  on  their  extensor  surfaces,  the 
humerus  forward  and  the  tibia  and  fibula  outward.  The  fre- 
quent deformities  of  the  joints,  like  genu  valgum  and  genu 
varum,  have  their  origin  in  the  rachitic  thickening  of  the 
epiphyses,  the  abnormal  relaxation  of  the  ligaments,  the 
traction  of  the  muscles,  and  the  weight  of  the  body. 

These  various  phenomena  are  not  well  marked  in  every 
case  and  may  frequently  occur  singly. 

DIRECT  RESULTS  OF  DISEASE  OF  THE  SKELETON 

In  craniotabes,  rubbing  of  the  head  upon  the  pillow 
causes  profuse  sweating  of  the  head  ;  the  cranium  is  ex- 
tremely sensitive  to  palpation.  Disease  of  the  teeth  in- 
terferes with  mastication  and  salivation,  thus  at  times  con- 
tributing to  the  gastro-intestinal  disturbances  so  frequently 
met  with  in  rachitis.  Disease  of  the  ribs  is  manifested 
by  pain  when  the  child  is  lifted  and  by  a  decrease  in  the 
thoracic  volume.  The  walls  of  the  thorax  being  yielding 
permit  the  muscles  of  the  chest  to  expand  it  sufficiently, 
excepting  in  certain  parts  where  the  intrathoracic  space 
is  diminished.  An  inspiratory  retraction  occurs  in  the 
neighborhood  of  the  insertion  of  the  diaphragm.  Dis- 
ease of  the  vertebral  column  and  of  the  extremities  make 
it  impossible  for  the  child  to  sit  up,  to  stand,  or  to  walk 
at  the  proper  period  of  life.  Frequently  the  subjects 
forget  what  they  have  already  learned  as  regards  walk- 
ing or  standing.  The  continuous  insufficient  ventilation 
of  the  lungs  results  in  a  decided  predisposition  to  bron- 
chial catarrh  and  bronchopneumonia. 

PHENOMENA  WHICH  ARE  NOT  DIRECTLY  DUE 
TO  DISEASE  OF  THE  SKELETON 

Characteristic  of  rachitis  is  its  pronounced  tendency  to 
disturbances  of  digestion.     The  dyspepsia  is  manifested 


COURSE  AND  PROGNOSIS.  121 

either  in  constipation  or  by  the  discharge  of  foul-smelling 
alcoholic  stools.  Meteorism,  which  is  nearly  always 
present,  causes  the  characteristic  enlargement  of  the 
abdomen,  forces  the  diaphragm  upward,  and  helps  to 
diminish  the  intrathoracic  space.  Anemia  is  only  rarely 
absent.  In  some  cases  the  number  of  red  blood-corpuscles 
is  reduced  to  two  or  three  millions  and  the  leukocytes  are 
increased.  The  skin  as  well  as  the  subcutaneous  tissue 
and  the  musculature  undergo  atrophy,  and  become  relaxed 
and  flabby  in  the  course  of  time.  Enlargement  of  the 
spleen  is  a  frequent  symptom,  but  not  constantly  present ; 
enlargement  of  the  liver  occurs  even  less  frequently.  In 
a  large  number  of  cases  there  is  a  certain  excitability  of 
the  nervous  system  which  shows  itself,  as  a  rule,  by  rest- 
lessness, peevishness,  and  crying,  and  in  some  cases  by 
more  serious  phenomena,  such  as  laryngospasm,  spasm  of 
the  glottis,  tetany  with  its  latent  and  manifest  symptoms, 
and  attacks  of  eclampsia.  (Concerning  these  symptoms, 
refer  to  their  respective  sections.) 

The  course  of  rachitis  is  prolonged  and  extends,  with 
intervals  of  improvement  and  exacerbation,  over  months 
and  even  years.  Although  the  various  phenomena  fre- 
quently arise  within  a  few  weeks,  their  disappearance  is 
gradual,  inasmuch  as  a  normal  growth  of  bone  must  first 
set  in.  The  large  amount  of  osteoid  tissue  which  is 
present  becomes  impregnated  with  lime  salts,  thus  devel- 
oping unusually  hard  and  compact  bones — "  ossaeburnea." 
The  primarily  soft  state  of  the  bones  is  thus  followed, 
after  a  certain  period  of  time,  by  an  abnormal  firmness. 
A  large  number  of  the  deformities,  even  the  pronounced 
ones,  are  corrected  without  artificial  aid  by  the  traction 
of  the  muscles,  provided  they  have  not  previously  under- 
gone ossification.  The  well-established  deformities,  how- 
ever, such  as  chicken-breast,  pronounced  bow-legs,  thick- 
enings of  the  cranium,  and  changes  in  the  pelvis,  remain 
unaffected  throughout  life.  If  craniotabes  only  is  present 
it  may  heal  without  the  appearance  of  other  symptoms. 

The  prognosis  of  the  disease  itself  is  favorable.  The 
association,  however,  of  rachitis  with  any  other  disease  is 


I 


122  RACHITIS 

a  serious  com})lication,  as  is  especially  true  of  pneumonia 
and  intestinal  diseases,  which  are  frequently  followed  by 
death. 

ETIOLOGY 

We  are  still  in  the  dark  as  to  the  real  cause  of  rachitis. 
Although  the  infectiousness  of  this  disease  has  been  fre- 
quently referred  to,  yet  it  has  never  been  proved ;  hered- 
itary influence,  however,  seems  to  play  a  very  important 
part.  In  favor  of  this  claim  is  the  existence  of  rachitic 
and  non-rachitic  families  liviijg  under  similar  unfavor- 
able hygienic  conditions  (Siegert).  Etiologically,  two 
factors  which  influence  the  general  health  are  of  prime 
importance,  namely:  1.  Long-continued  living  in  foul 
air  (small,  dark  rooms,  overcrowded  rooms,  damp  floors, 
or  cellars).  2.  Improper  feeding,  in  which  the  sj)ecial 
form  of  nourishment  is  of  less  importance  than  the  indi- 
vidual digestive  ability  of  the  child.  Artificially  fed 
children  are  more  frequently  diseased  than  breast-fed 
infants ;  the  latter  are,  however,  by  no  means  immune  to 
rachitis. 

In  order  to  understand  the  morbid  anatomy  of  rachitis 
it  is  of  importance  to  understand  the  processes  concerned 
in 

NORMAL  OSSIFICATION 

We  distinguish  between  bones  preformed  in  cartilage 
(primary)  and  bones  developed  from  a  connective-tissue 
(secondary)  foundation.  Each  type  presents  a  different 
form  of  development : 

Bones  Preformed  in  Cartilage. — This  type  presents  three 
main  processes  of  bony  develojiment : 

Absorption  of  the  cartilage  and  its  substitution  by  bony 
tissue — endochondral  ossijication. 

Deposition  of  newly  formed  bony  tissue  at  the  periph- 
ery— periosteal  ossification . 

The  reabsorption  of  fully  developed  bone,  wliich  is  of 
importance  in  the  building  and  nourishing  of  bone. 

This  constant  bony  growth  from  without  and  destruc- 
tion from  within  occurs  alike  in  all  bones,  and  causes  a 


NORMAL   OSSIFICATION  123 

decidedly  active  local  metabolic  process  during  the  period 
of  development.  Endochondral  ossification  is  only  seen 
at  the  epiphyses  of  the  long  bones  where  longitudinal 
growth  occurs,  whereas  the  diaphysis,  which  is  likewise 
originally  preformed  in  cartilage,  is  already  ossified  (endo- 
chondral), and  continues  to  grow  only  in  width  through 
periosteal  ossification. 

The  transit  of  cartilage  into  bone  is  performed  within 
two  narrow  zones:  1.  An  upper  pale  blue  and  slightly 
swollen  layer,  the  zone  of  cartilage  proliferation.  2. 
Below  it  a  thinner  whitish  layer,  the  zone  of  provisional 
calcification.  Endochondral  ossification  occurs  as  follows  : 
In  the  upper  zone  the  cartilage  cells  become  swollen  and 
arrange  themselves  in  rows  and  columns.  Next  the  soft 
cartilaginous  ground  substance  begins  to  harden  by 
impregnation  with  calcium  salts,  the  cartilage  cells  become 
enclosed,  and  their  further  growth  is  arrested.  Blood- 
vessels accompanied  by  a  large  number  of  cells  (osteo- 
blasts) now  extend  from  the  medullary  space  of  the  di- 
aphysis ^  into  the  cartilage  prepared  as  above,  which 
absorb  the  calcified  cartilaginous  ground  substance,  and 
causing  the  disappearance  of  the  cartilage  cells,  build 
primary  medullary  s])accs.  Each  column  of  cartilage 
cells  represents  a  medullary  space  ;  the  latter  are  sepa- 
rated from  each  other  by  undisturbed  processes  of  calci- 
fied cartilaginous  ground  substance.  The  osteoblasts  now 
settle  everywhere  on  the  walls  of  these  trabeculae  and 
begin  the  development  of  the  bony  ground  substance, 
which  is  free  of  cells — the  osteoid  tissue.  The  osteo- 
blasts become  gradually  surrounded  by  this  tissue,  cease 
to  build  bone,  and  become  permanent  bone-cells.  Simul- 
taneously the  osteoid  tissue  takes  up  the  lime  salts  and  is 
converted  into  completed  bone-tissue.  While  the  primary 
medullary  spaces  become  filled  in  this  manner  with  bone- 
tissue,  a  simultaneous  absorjition  of  the  newly  built  bone 
again  is  brought  about  by  the  activity  of  a  certain  group  of 
large  cells — the  osteoclasts.  Thus  are  formed  the  definite 
medullary  spaces  of  tlie  spongiosa.  Isolated  remnants 
'  Or  from  the  tissue  lyins?  beneath  tlie  perichondriuni. 


124  RACHITIS 

PLATE  6 

FiG.l.  Bony  Development.— Portion  of  a  lougitudinal section  through 
the  metacarpal  bone  of  a  five- mouths' -old  embryo.  Magnified  50  times. 
The  figure  shows  the  border  of  the  endochondral  ossification  zone  and 
the  changes  the  cartilage  passes  through  before  it  is  absorbed.  Exter- 
nally at  the  perichondrium  is  a  layer  of  perichondral  bone.  1.  Endo- 
chondral bone.  2.  Cartilage.  3.  Zone  in  which  cartilage  cells  form 
columns.  4.  Zone  of  enlarged  cartilage  cavities  with  temporary  calcifica- 
cation  of  the  ground  substance.  5.  Rudiments  of  calcified  ground 
substance.  6.  Marrow.  7.  Periosteal  bone.  8.  Giantcells  (osteoclasts). 
(From  Sobotta's  Atlas  of  Histolog;/.) 

Fig.  2.  Normal  border  between  bone  and  cartUage  of  the  upper 
epiphysis  of  the  femur  of  a  scven-months'-old  fetus  (premature  birth 
due  to  trauma  to  mother).  Magnified  6  times.  The  border  between 
the  bone  and  cartilage  runs  as  a  slightly  curved  but  regular  and  con- 
tinuous line ;  the  individual  layers  are  easily  distinguished  from  one 
another.  1,  Unchanged  cartilage.  2.  Zone  of  growing  cartilage.  3. 
Zone  of  temporary  excretion  of  lime.  4.  Zone  in  which  medullary  spaces 
are  constructed.     5.  Endochondral  bone.     6.  Periosteal  bone.     7.  Mar- 


of  calcified  cartilaginous  ground  substance  are  always 
found  in  endochondral  bone. 

Periosteal  ossification  (apposition  of  bone),  which  occurs 
primarily  only  at  the  diaphy.sis,  but  later  at  the  epiphysis 
also,  is  formed  as  follows :  The  osteoid  tissue  situated 
beneath  the  perichondrium  is  converted  into  bone  sub- 
stance or  osteoid  ti.ssue.  The  penetration  of  blood-vessels 
and  osteoblasts  into  the  bone  substance  leads  to  the  forma- 
tion of  Haversian  canals,  trabeculse,  and  lamellae ;  here 
also,  extending  toward  i}\e  spongiosa,  an  absorption  of  the 
bone  occurs  through  osteoclasts. 

Connective-tissue  Bone. — Single  bundles  of  connective 
tissue  become  calcified  ;  osteoblasts  which  are  derived  from 
embryonal  cells  are  de]>osited  upon  these  calcified  bundles, 
and  form  bone  in  the  same  manner  as  above. 

PATHOLOGIC  ANATOMY   OF   RACHITIS 

Macroscopic  Changes. — A  fresh  rachitic  bone  is  flexible, 
frequently  cylindric  in  shape, and  of  les.sened  consistency; 
its  periosteum  is  thickened  and  liyperemic.  Such  a  bone 
presents  the  thickening,  .swelling,  .softening,  and  partial 
fractures  which  were  described  above.  The  amount  of 
calcium  is  reduced  from  30  to  50  per  cent.     On  section 


Fiy.2. 


PATHOLOGIC  ANATOMY  OF  RACHITIS  125 

the  epiphysis  of  a  long  bone  is  found  to  be  enlarged  in 
all  directions,  the  walls  of  the  diaphysis  thickened,  the 
wall  of  the  medullary  canal  narrowed,  and  the  spongiosa 
and  marrow  red  and  congested.  At  the  junction  between 
the  bone  and  cartilage  the  following  conditions  are  ob- 
served : 

The  cartilage  seems  to  be  thickened  externally  and 
driven  forward. 

The  zone  of  cartilaginous  growth  is  darker,  swollen, 
and  plainly  increased  in  width. 

The  limiting  zone  between  the  bone  and  cartilage, 
which  is  normally  straight,  is  irregular  or  indented. 

Microscopic  Changes. — Endochmidral  Bone. — Normally 
the  cartilage,  the  zone  of  calcification,  and  spongiosa  are 
arranged  in  rows  one  after  the  other,  but  in  rachitis  this 
order  is  disturbed.  The  border-line  of  the  process  of 
calcification  is  interrupted  and  the  tissues  are  irregularly 
placed  and  are  intermingled  with  each  other.  Thus  we 
find  in  growing — and  even  in  the  quiescent — cartilage 
areas  of  calcified  ground  substance,  and,  indeed,  osteoid 
tissue  foci  in  which  medullary  spaces  are  being  formed. 
On  the  other  hand,  separated  foci  of  calcified  and  de- 
calcified cartilage  are  seen  in  the  spongiosa.  There  is 
temporary  insufficient  excretion  of  the  lime  salts.  In 
the  spongiosa  the  osteoid  tissue — that  is,  the  bony  sub- 
stance which  is  still  decalcified — is  thickened  ;  an  insuf- 
ficient calcification  of  bony  tissue  occurs  in  this  area. 

Periosteal  and  Connective-tissue  Bone  (see  Plate  8,  Fig. 
2). — Growth  of  the  inner  periosteal  layer;  broadening 
of  the  osteoid  substance  and  deficient  excretion  of  calcium 
salts  in  the  same ;  in  consequence  there  is  but  a  small 
amount  of  real  bony  tissue.  The  bony  trabeculse  become 
calcified  within,  but  remain  soft  at  the  periphery,  which 
accounts  for  the  flexibility  of  the  bones.  The  reddened 
bone-marrow  shows  an  increase  of  red  blood-cells. 

The  explanation  of  the  rachitic  process  which  is  most 
generally  accepted  at  the  present  time  is  that  of  Pauer : 
The  process  of  ossification  pauses  as  it  reaches  the  stage 
when  normally  lime  salts  are  being  excreted.     On  the 


126  RACHITIS 

PLATE  7 
Rachitis  at  the  Junction  of  the  Bony  with  the  Cartilaginous  por- 
tion of  a  Rib.  Enlarged  8  times.  The  bony  cartilaginous  junction  is 
irregularly  formed ;  the  zone  of  provisional  calcification  is  absent ;  the 
cartilage  has  undergone  excessive  proliferation ;  the  formation  of  medul- 
lary spaces  and  cartilaginous  proliferation  occurs  in  the  same  plane  side 
by  side.  1.  Quiescent  cartilage.  2.  Proliferated  cartilage  which  has  led 
to  lateral  protrusion.  3.  Columns  of  cartilage  cells.  4.  Columns  of 
cartilage  cells  which  have  penetrated  the  zone  of  medullary  spaces.  5. 
Primary  marrow  which  has  penetrated  from  the  medullary  spaces  deeply 
into  the  cartilage.  6.  Indication  of  provisional  excretion  of  lime  (dark 
color).  7.  Osteoid  tissue  of  periosteal  origin,  which  is  thickened  and 
poorly  supplied  with  lime.  8.  Thickened  osteoid  tissue  which  is  endo- 
chondral in  origin.    9.  Marrow. 

one  hand,  the  temporary  calcification  of  the  cartilaginous 
ground  substance  is  insufficient,  while  on  the  other  hand, 
there  is  imperfect  transformation  of  the  osteoid  substance 
(containing  no  lime  salts)  into  bony  tissue,  which,  although 
similar  in  structure,  contains  calcium  salts.  The  results, 
therefore,  are  of  two  kinds : 

If  the  boundary  line  between  cartilage  and  bone  is 
absent,  together  with  the  zone  of  calcification,  the  regular 
and  necessary  arrangement,  in  which  the  column  of  carti- 
lage cells  and  a  primary  medullary  space  face  each  other, 
is  not  preserved,  so  the  absorption  of  the  cartilage  cells 
does  not  proceed  at  equal  stages.  Without  a  limiting 
line  the  two  tissues  grow  past  each  other  without  any 
order.  Thus  are  explained  the  serrated  edges  and  inter- 
mingling of  the  layers,  the  presence  of  primary  medullary 
spaces  in  the  cartilage,  and  of  cartilaginous  foci  in  the 
bone,  etc.  Such  a  process  naturally  arrests  the  growth 
of  the  bone  in  its  longitudinal  axis. 

If  in  spite  of  the  insufficient  further  g^o^vth  of  these 
two  tissues,  the  growth  of  the  cartilage,  the  formation  of 
lai^e  vesicular  projierly  arranged  cartilage  cells,  as  well 
as  the  deposition  of  osteoid  tissue,  proceeds  uninterrupted, 
excessive  tissue  forms  on  both  sides,  which  hinders  the 
transformation  into  the  next  stage.  This  excessive 
amount  of  unfinished  ti.ssue  spreads  out,  and  thus  leads 
to  the  characteristic  cartilage  and  bony  swellings.  The 
latter  are  not,  therefore,  due  to  an  active  proliferation, 
but  to  arrested  development  of  the  bone-building  tissues. 


<s„-r 


■W 


MV-': 


^^^■^M 


S— 


f 


my^.: 


DIFFERENTIAL  DIAGNOSIS  .  127 

In  the  case  of  periogteal  and  connective-tissue  bone 
practically  tlie  same  processes  are  concerned,  that  is,  un- 
limited deposition  of  osteogenetic  layers  upon  the  surface 
of  the  bone  and  deposition  of  osteoid  tissue  within,  with 
faulty  or  imperfect  conversion  into  fully  developed  bone. 
Such  is  the  origin  of  the  enlarged  cranial  protuberances; 
the  craniotabes  is  explained  by  either  an  excessive  resorp- 
tion of  the  newly  formed  bone  or  by  a  lack  of  bony  appo- 
sition with  undisturbed  resorption.  Insufficient  excretion 
of  calcium  salts  is  undoubtedly  accompanied  (in  certain 
cases  of  rachitis)  by  an  osteoporosis,  that  is,  excessive 
resorption  of  fully  developed  osseous  tissue,  which,  espe- 
cially in  the  severe  osteomalacic  form,  is  accompanied  by 
extreme  deformities ;  hence  the  permanent  abnormally 
soft  consistency  of  such  bones.  The  innumerable  theories 
advanced  as  to  the  pathogenesis  of  rachitis  are  still  too 
uncertain  to  permit  of  discussion  here. 

DIAGNOSIS 

This  is  not  difficult  in  typic  cases.  The  beginning  of 
rachitis  may  be  recognized  by  increasing  restlessness, 
sweating  of  the  head,  increasing  pallor,  pain  on  being 
lifted,  and  dyspepsia  without  any  apparent  reason. 

DIFFERENTIAL  DIAGNOSIS 

Hydrocephalus  The  Eachitic  Head 

Rounded,  with  protruding  fron-  Angular;  fontanels  often  covered 

tal  and  teni|X)ral  bones ;  fontanels      by  the  overlapping  edges  of  the 
are  arched   outward  and   widely      bones ;  craniotabes.    No  symptoms 
open.      Lack   of   proportion    be-      of  cerebral  pressure, 
tween  the  small   facial   and    the 
large  cranial  portion  of  the  skull, 
('onvergent  strabismus.     Signs  of 
cerebral  pressure ;  mental  disturb- 
ances. 


Kyphosis  of  Spondylitis  Rachitic  Kyphosis 

Forming  a  sharp  angle;   lying  Roum 

_ion  alxlomen  does  not  cause  it  to  the  abd( 

disappear.  painless, 


Forming  a  sharp  angle;   lying  Round  ;  disappears  in  time  when 

upon  alxlomen  does  not  cause  it  to      the  abdominal  posture  is  assumed ; 


12S  hachitis 

PLATE  8 

Fig.  1.  Fetal  Chondrodystaroplila.— The  distal  epiphyseal  border  of 
the  tibia  of  an  almost  full-term  iufaut  which  was  dead  when  boru. 
Magnified  41  times.  The  bony  cartilaginous  border  shows  gross  irreg- 
ularities. The  cartilage  protrudes  somewhat  in  a  lateral  direction. 
Endochondral  bone  growth  is  hindered  by  the  fact  that  the  quiescent 
cartilage  is  not  transformed  into  large  vesicular  cells  with  their  arrange- 
ment into  columns,  because  of  the  entrance  of  connective-tissue  processes 
from  the  perichondrium  between  the  cartilage  and  diaphysis.  In  place 
of  the  columnar  cartilage  there  is  found  a  spongy  degenerated  cartilage 
tissue.  Temporary  calcification  is  only  suggested  here  and  there ; 
primary  medullary  spaces  are  absent;  the  cartilage  rests  in  certain 
areas  directly  upon  the  marrow  and  bone  tissue.  The  bony  trabecular  of 
the  spongiosa  are  few  and  thickened  and  the  medullary  spaces  widened. 
The  periosteal  bony  growth — that  is,  the  growth  in  width— is  only 
slightly  disturbed.  A  plate  of  periosteal  bone  grows  over  the  cartilage 
for  some  distance.  1.  Quiescent  cartilage.  2.  Hyaline  degenerated  ciir- 
tilage.  3.  Connective-tissue  process  growing  inward  from  the  perichon- 
drium. 4.  Temporary  calcification.  5.  Periosteal  bony  laniellaj.  6.  En- 
larged medullary  space.  7.  Periosteal  bony  plate.  (Preparation  of  Prof. 
Stoeltzner.) 

Fig.  2.  BacMtis  of  a  Flat  Cranial  Bone.  Craniotabes.— Enlarged 
52  times.  The  osteogenetic  layer  of  the  periosteum  is  richly  supplied 
with  cells  and  is  increased  in  size  by  proliferation.  Between  its  fas- 
ciculi are  embedded  narrow  indentations  and  trabeculse  of  j'oung  bone 
tissue  which  are  periosteal  in  origin.  Toward  the  center  the  trabeculse 
lie  closer  together  and,  finally,  form  a  connected  cortex.  The  excretion 
of  lime  salts  is  insuflicient  in  amount.  Although  the  outermost  (youngest) 
bony  trabeculse  still  plainly  show  calcification  in  their  centers,  yet  the 
cortex  is  composed  almost  entirely  of  decalcified  osteoid  tissue.  The 
inner  surface  of  the  bone  is  serrated  on  account  of  the  aetive  absorption 
of  bone  by  the  osteoclasts.  1.  Fibrous  layer  (periosteum).  2.  Osteogenetic 
layer  (periosteum).  3.  Calcified  bony  tissue.  4.  Osteoid  tissue,  possess- 
ing no  calcium  salts.  5.  Cortex  poorly  supplied  with  lime.  6.  Osteo- 
clasts.    (Preparation  of  Prof.  Heubner.) 


Moller-Baelow's  Disease  Rachitis 

Qinical 

Sensitive  to  movement   of  the  Pain   on   moving  thoi-ax.     Al- 

lower  extremities.     Painful  .swell-  most  painless  swelling  of  the  e[)i- 

ing  of  the  epiphyses,  especially  of  physeal  cartilages   of    the   upper 

the   lower    extremities.      Specific  and     lower    extremities.      Gums 

disease  of  the  gnras.     No  response  intact, 
to  the  rachitic  treatment ;  follows 
use  of  uncooked  food. 

Anatomic 

Hemorrhages  into  bone-marrow  Insufficient  bone  formation,  Ab- 

and  periosteum ;  characteristic  de-  senoe  of  oixler  in  the  process  of 

generation  of  the  bone-marrow.  ossification. 


'■Jl 


J  - 


f 


^v.c:* 


/>«.  7 . 


7^. 


^.^ 


,-<5 


Fig.2. 


THE  TREATMENT  OF  RACHITIS 


129 


Syphilitic  Osteochondritis 


Rachitic    Swelling    of    the 
Epiphyses 

Clinical 


Occurring  during  first  weeks  of 
Ufe. 

Painful. 

Swelling  usually  of  only  one 
lower  epiphysis  of  the  humerus 
or  femur.  In  severe  cases  separa- 
tion of  the  epiphysis  and  pseudo- 
paralysis. 


Occurring  usually  during  the 
last  half  of  tii-st  year  of  life. 

Almost  painless. 

Multiple  epiphyseal  swellings 
in  all  extremities. 


Anatomic 


Irregular  borders  between  carti- 
lage and  bone,  which  are  pointed, 
rough,  and  serrated. 


Narrowed  zone  of  cartilage  pro- 
liferation. 

Enlarged  zone  of  temporary 
calcification. 

Interference  with  construction 
of  organic  (osteoid)  tissue,  asso- 
ciated with  undisturbed  deposition 
of  the  inorganic  (calcium)  sub- 
stance. 

Chondrodystrophia 

Interference  with  longitudinal 
gi'owth  of  the  tubular  bones,  asso- 
ciated with  undisturted  growth  in 
width,  in  consequence  of  a  ces- 
sation in  cartilaginous  proliferation 
due  to  the  intergrowth  of  connec- 
tive tissue. 

Appears  to  be  congenital. 

Incurable. 


Irregular  border  between  carti- 
lage and  bone,  which  is  rounded 
oflj  and  presents  serrated  notches 
which  feel  soft  to  the  palpating 
hand. 

Thickened  zone  of  cartilage  pro- 
liferation. 

Partial  or  complete  absence  of 
zone  of  temporary  calcification. 

Insufficient  deposition  of  the  in- 
organic (calcium)  substance,  asso- 
ciated with  undisturbed  formation 
of  organic  (young  bone)  substance. 


Rachitis 

Disturbance  of  all  bony  growth, 
on  account  of  insufficient  deposi- 
tion of  calcium,  and  the  effects 
which  arise  thereform. 


Occurs  during  early  life  of  in- 
fant. 
Curable. 


THE   TREATMENT   OF   RACHITIS 

Both  as  a  preventive  and  as  a  cure  it  is  of  prime  im- 
portance to  combat  the  injurious  effects  of  a  bad  atmo- 
sphere. Provide  fresli  air  in  the  room  or  insist  upon 
sojourn  in  the  open  air  (even  when  the  weather  is  bad); 
much  sunshine.  [Many  of  the  leading  clinicians  abroad 
9 


130  RACHITIS 

send  their  little  patients  to  the  seacoast,  believing  they 
are  benefited. — Ed.] 

Diet. — As  a  prophylactic  measure,  the  child  should  be 
fed  on  modier's  milk  or  that  of  a  wet-nurse  ;  or,  as  a  sub- 
stitute, raw  milk  properly  modified  and  animal  broths 
made  from  fresh  bones.  Limit  starchy  food.  Fruit 
juices  are  considered  antirachitic.  At  the  end  of  the 
first  half  year  allow  a  mixed  diet,  with  the  addition  of 
fresh  vegetables,  vegetable  broths,  potatoes  and  chopped 
meat,  scraped  or  crushed  fruit. 

Salt  or  brine  baths  (32°  to  35°  C.  [89.6°-95°  F.],  see 
p.  70)  two  or  three  times  a  week,  for  a  period  not  longer 
than  four  weeks.  Exercise  judgment  in  case  of  weak 
children.  Mild  massage  ;  rub  off  with  brandy  or  bathe 
with  eau  de  Cologne ;  in  midsummer,  short  sun-baths. 
The  soft  bones  should  be  spared  in  carrying,  standing,  or 
walking.  Corrective  movements  indicated  for  the  curva- 
tures. Osteoclasis  and  other  orthopedic  procedures. 
Osteotomy.  [Since  many  of  the  rachitic  deformities  of 
the  extremities  tend  toward  spontaneous  cure,  no  surgical 
intervention  should  be  employed  until  at  least  the  fifth  or 
sixth  year. — Ed.] 

Medication. — Phosphorus,  0.01  :  lOOgm.  (ioo~:iOgg^-)  » 
cod-liver  oil,  1  coffeespoonful  once  or  twice  a  day.  Gart- 
ner's phosphoretted  chocolate  plates,  of  each  4  mg.  In 
this  manner  a  favorable  influence  is  producecf  upon  the 
general  condition,  especially  upon  the  nervous  and  spas- 
modic })henomena.  To  combat  the  anemia  give  iron  or 
the  iodid  of  iron,  and  later  give  the  compound  tincture 
of  cinchona  in  1-drop  doses.  Somatose.  For  the  sweats 
give  vinegar-water,  10  per  cent,  vinegar  spirits. 


CONGENITAL  DISTURBANCES  IN  BONE  DEVELOPMENT 

{Fetal  Rachitis;   Imperfect    Osteogenesis;    Congenital  Achondroplasia; 
Fetal  Myxedema) 

Purely  congenital  rachitis  is  rarely  encountered.     The 
conditions  which  have  been  described  under  this  name 


I 


DISTURBANCES  IN  BONE  DEVELOPMENT       131 


Fig.  44. — Imperfect  osteogenesis  (fetal  radiitis).  Girl  of  eight 
months.  The  extremities,  which  in  comparison  with  the  length  of  the 
body  are  abnormally  short,  show  deformities  and  healed  fractures.  Mild 
macroglossia ;  head  slightly  hydrocephalic.  Death  following  bronchitis. 
(Escherich's  Clinic,  Vienna.) 


132  RACHITIS 

Fig.  45. — Fetal  Achotidroplasia.  Skeleton  of  a  micromelic  dwarf. 
Bones  of  the  extremities  short  and  thick,  with  wide — especially  at  the 
knee — and  considerably  thickened  epiphyses.  No  fractures.  (Graz  Patho- 
logic Institute.) 

Fig.  46. — Fetal  Achondroplasia.  Pure  type.  The  extremities  are 
shortened,  but  not  deformed  or  fractured.     (Clinic  of  Pfaundler,  Graz.) 

Fig.  47. — Fetal  Achoiidroplania.  Skiagram  of  foregoing  case,  showing 
the  shortened  long  bones  of  the  extremities,  without  deformities  or 
fractures,  and  their  enlarged  epiphyses.  It  may  be  seen  from  the 
intensity  of  the  shadows  that  a  certain  amount  of  sclerosis  exists. 
(Clinic  of  Pfaundler,  Graz.) 

should  be  classified  either  under  imperfect  osteogenesis, 
achondroplasia,  or  fetal  myxedema. 

Imperfect  Osteogenesis. — The  child's  extremities  at  birth 
arc  abnormally  short  and  plump,  and  show  considerable 
distortion  and  fractures.  Crepitation  is  plainly  felt  in 
the  flat  cranial  bones,  the  jaws,  the  pelvis,  etc.  The  rest 
of  the  body,  as  a  rule,  shows  nothing  abnormal.  The 
child  may  continue  to  live.     The  cause  is  unknown. 

Morbid  Anatomy. — The  short  and  thick  tubular  bones 
show  a  thin  cortex,  a  brittle  and  sparse  spongiosa,  and 
enlarged  medullary  spaces ;  multiple  fractures.  The 
zones  of  cartilaginous  proliferation,  the  progress  of  calci- 
fication, and  the  formation  of  primary  medullary  spaces, 
in  the  main,  occur  normally  ;  on  the  other  hand,  how- 
ever, there  is  great  irregularity  in  the  formation  of  real 
bone.  The  bony  trabecule  are  lacking  in  size  and  num- 
ber and  are  not  arranged  in  lamellae ;  the  development 
of  the  bone-forming  cells — the  osteoblasts — is  faulty,  and 
they  fail  to  functionate  properly  ;  there  is  also  excessive 
absorption  of  bone  tissue. 

The  endochondral  ossification  is  usually  disturbed  to  a 
greater  extent  than  the  periosteal  (see  also  Normal  Ossi- 
fication, p.  122) ;  the  marrow  is  poor  in  cells,  gelatinous, 
and  "  inactive."  Ossification  is  undisturbed  and  callus 
forms  at  the  site  of  the  fractures.  The  thyroid  gland  is 
normal  (Harbitz). 

Congenital  Achondroplasia. — The  extremities  are  nota- 
bly short,  usually  straight,  but  at  times  somewhat  curved. 
No  fractures.  A  pure  form  of  dwarf  growth.  The  bones 
are  hard,  sclerosed,  and  the  epiphyses  thickened. 


Fig.  45. 


133 


X 


Fia.  46. 


134 


Fig.  A', 


135 


136  RACHITIS 

PLATE   9 

Barlow's  Disease. — A  portion  of  Fig.  49,  which  represents  the  area 
marked  by  a  rectangle.  Enlarged  150  times.  1.  Large  vesicular  carti- 
lage cells.  2.  Temporary  calcification  of  cartilaginous  ground  substance. 
3.  Youngest  bony  tra been  lie.  4.  Endosteal  hemorrhage.  5.  Subperi- 
osteal hemorrhage.  6.  Bony  trabeculsB  disappearing  on  account  of  bony 
absorption.     7.  Fibroid  degeneration  ;  marrow  poor  in  cells. 


FIGURE  49 

Barlow's  Disease. — Longitudinal  section  of  a  distal  epiphysis  of 
the  femur.  Enlarged  5  times.  (As  the  artist  unfortunately  broke  the 
preparation,  it  had  to  be  repaired  and  somewhat  reconstructed  at  the 
line  of  fracture;  it  is  therefore  undecided  whether  a  fracture  occurred 
during  the  disease  or  whether  one  existed  before  that  period.)  Hemor- 
rhages (red)  are  noted  spreading  underneath  the  periosteum,  as  well  as 
within  the  spougiosa,  where  they  are  especially  well  marked  in  the 
vicinity  of  the  line  between  the  cartilage  and  bone  (loosening  of  the 
epiphysis  usually  occurs  at  this  point).  The  zone  of  proliferation,  espe- 
cially of  the  columnar  arranged  cells,  is  broadened.  Underneath  this  is 
a  narrow  irregular  zone  of  temporary  calcification ;  connecting  with  it 
are  young  bony  trabeculae  (blue),  which  are  well  developed,  but  few  in 
number;  near  the  diaphysis  they  become  converted  (through  excessive 
bony  absorption  and  crowding  in  of  marrow  tissue)  into  small  closely 
crowded  bony  trabeculae.  This  gives  the  spongiosa  a  checkered  appear- 
ance. The  cortex  cannot  be  distinguished,  for  it  has  disappeared  as  the 
result  of  a  pathologic  increase  of  bony  absorption.  (From  a  preparation 
of  Prof.  Schmorl,  in  the  possession  of  Geh.-Eat  Heubner.) 


Microscopically  are  seen  :  Disturbance  of  the  endo- 
chondral os.sification  by  limitation  of  cartilaginous  pro- 
liferation (no  column  formation  of  cells),  and  the  pene- 
tration between  cartilage  and  bone  of  perichondral 
connective  tissue.  These  disturbances  interfere  with  the 
longitudinal  growth.  The  asymmetric  growth  of  perios- 
teal strips  leads  to  disproportionate  development  and 
the  formation  of  deformities.  (Histology  of  Achondro- 
plasia, see  Plate  8,  Fig.  1 .) 

Fetal  Mjrxedema. — The  infant  presents  the  phenomena 
of  a  pronounced  case  of  myxedema,  including  thick,  dry 
skin,  peculiar  expression  of  face,  large  head,  and  ]>lump 
body.  The  extremities  are  short  and  thick.  The  thyroid 
gland  is  imperfectly  or  excessively  developed.  Anatom- 
ically the  bones  are  the  seat  of  achondroplasia  or  imper- 
fect o-steogenesis.  Such  children  are  either  still  born  or 
live  but  a  short  time  as  micromelic  dwarfs. 


iiif-'  ■  # 


5-  ^'-T  t 


>./^ 


I  I 

■  ! 

6        7 


Fig.  49. 


BARLOW'S  DISEASE  137 


BARLOW'S   DISEASE 


Infickiitile  Scorbutus:  Acute  Hemorrhagic  Bachitis. — 
This  is  a  peculiar  disturbance  of  nutrition,  wliich  can  be 
classified  neither  with  scorbutus  nor  with  rachitis.  It  is 
a  disease  process  of  the  osseous  system,  accompanied  by 
distinct  changes  in  the  bones  and  a  tendency  to  hemor- 
rhage. 

Occurrence. — It  develops  in  the  first  or  second  half 
year  of  life  and  almost  exclusively  in  artificially  fed  chil- 
dren.* It  seems  to  affect  especially  the  well-to-do  middle 
class,  and  is  frequently  combined  with  rachitis. 

Symptoms. — Severe  pain  upon  movement,  especially  of 
the  lower  extremities ;  adduction  of  the  legs ;  livid  color 
of  the  face  with  increasing  pallor  of  the  skin ;  extreme 
weakness.  Painful  swelling  of  the  epiphyses  of  the  knee 
or  of  the  diaphyses  of  one  or  both  femurs.  At  a  later 
stage  in  the  disease  there  is  also  epiphyseal  swelling  of 
the  tibia  and  the  arms.  The  skin  over  the  swellings  is 
tense,  shiny,  whitish,  and  (rarely)  bluish  red.  There  is 
extravasation  of  blood  in  the  gums,  which  may  be  recog- 
nized by  the  presence  of  little  bluish-red  masses  between 
the  teeth. 

Occasional  Phenomena. — Hemorrhagic  swellings  of  the 
ribs,  scapula,  and  in  the  orbits,  where  the  eyeballs  are 
pushed  forward ;  hemorrhages  of  the  skin  and  mucous 
membranes;  hemorrhagic  nephritis.  (For  Differential 
Diagnosis  between  it  and  Rachitis,  see  p.  128.) 

Course. — This  disease  lasts  for  weeks  and  months,  and 
if  the  proper  treatment  is  instituted  the  prognosis  is 
always  favorable. 

Morbid  Anatomy. — The  swellings  are  due  to  hemor- 
rhages in  and  under  the  periosteum,  as  well  as  between 
the  spongiosa  and  bone.  As  a  result  of  the  latter  we  have 
epiphyseal  separation  and  greenstick  fractures.  Another 
phenomenon  is  a  peculiar  degeneration  of  the  highly  cel- 

'  Whose  food — no  matter  in  what  form — is  constantly  heated  to  the 
boiling-point  Definite  food  preparations  or  sterilization  need  not 
necessarily  cause  this  condition  (Heubner). 


138  BTSEASES  OF  THE  THYMUS  GLAND 

lular  bone-marrow,  consisting  of  conversion  into  loose 
connective  tissue,  which  is  but  poorly  supplied  with  blocxl- 
vessels  and  cells.  The  osteoblasts  disappear,  the  spongi- 
osa  undergoes  softening  and  destruction.  The  general 
growth  of  the  bone  is  interfered  with. 

Treatment. — Barlow's  disease  is  highly  responsive  to 
treatment.  Administer  raw  milk  or,  if  not  feasible,  give 
milk  which  has  been  boiled  as  little  as  possible.  When 
necessary  dilute  the  milk  with  uncooked  solutions  of 
infant  meal,  nutritive  sugar,  etc.  Also  give  the  juice  of 
raw  meat  and  uncooked  fruits,  green  vegetables,  and 
mashed  potato. 

DISEASES  OF  THE  THYMUS  GLAND 

STRUMA 

Enlargement  of  the  thymus  gland  involves  one  or  more 
of  its  lobes.  Anatomically  struma  is  usually  of  the  par- 
enchymatous form  (soft),  rarely  of  the  colloidal,  cystic,  or 
fibrous  variety. 

Etiology. — It  is  frequently  hereditary  and  is  influenced 
by  peculiar  geographic  conditions  (endemic  goiter).  Other 
causes  are  tight  collars,  development  of  puberty,  and  not 
infrequently  this  condition  is  caused  by  continued  lying 
on  the  abdomen.  Dorsal  flexion  of  the  head  during 
infancy,  incorrect  position  when  Avriting  (school  goiter), 
and  pertussis  are  also  of  etiologic  interest. 

Complications. — Compression  of  the  trachea ;  noisy, 
dyspneic  respiration;  compression  of  the  jugular  veins; 
mental  disturbances  ;  vertigo ;  headache. 

Course. — Usually  favorable. 

Treatment. — When  possible,  the  cause  must  be  elimi- 
nated. The  neck  should  be  free  from  clothing,  and  if 
the  subject  is  an  infant  it  should  be  allowed  to  assume 
none  but  the  dorsal  position.  Inunctions  of  pota.ssium 
iodid  ointment  should  be  resorted  to  as  well  as  the  tinct- 
ure of  iodin  and  of  nutgalls  ;  thyroid  extract  tablets  (see 
p.  145).    [Favorable  results  are  being  constantly  obtained 


HYPOTHYROIDISM.     DYSTHYROIDISM.  139 

by  the  administration  of  thyroid  extract  in  doses  of  from 
1  to  5  gr.  t.  i.  d.  These  patients  should  be  carefully 
watched  for  the  physiologic  symptoms,  such  as  rapid 
pulse,  loss  of  weight,  pyrexia,  and  diarrhea.  Drugs 
should  be  stopped  when  either  of  these  symptoms  occur. 
When  there  is  mechanical  interference  with  the  trachea 
or  great  vessels,  surgical  intervention  is  indicated. — Ed.] 

BASEDOW'S  DISEASE 

This  condition  depends  upon  excessive  function  of  the 
thyroid  gland.  The  cardinal  symptoms  include :  Pul- 
sating goiter,  exophthalmos,  palpitation  with  hypertrophy 
of  the  heart,  which  is  often  incompletely  developed, 
sweats,  dyspnea,  tremor,  excitability,  and  a  feeling  of 
fear. 

Course. — Basedow's  disease  runs  a  chronic  course.  The 
result  is  either  complete  recovery  with  enlargement  of  the 
heart,  or  death  due  to  cardiac  failure  or  some  intercurrent 
affection. 

Treatment.: — The  treatment  consists  in  rest,  an  easily 
digestible  diet,  especially  milk  ;  fresh  air  and  mild  hydro- 
therapeutic  procedures.  A  trial  should  be  made  with 
myxedema  serum,  "  Rodagen  "  (Merck-Moebius). 

HYPOTHYROIDISM.      DYSTHYROIDISM 

These  terms  are  applied  to  all  diseases  due  to  faulty  or 
to  complete  absence  of  the  function  of  the  thyroid  gland. 
In  such  cases  only  a  rudimentary  gland  exists  and  some- 
times cannot  be  felt  (athyroidia).  Clinically  the  follow- 
ing groups  of  symptoms  may  be  distinguished  : 

Chronic  Benign  Hypothyroidism  (Hertoghe). — This  is 
usually  not  recognizable  until  the  second  or  third  decade 
of  life.  Sexual  instinct  undeveloped ;  beardless  face  ; 
childish  voice  ;  narrow  thorax  ;  dryness  of  hair.  During 
childhood  it  is  often  preceded  by  wetting  of  the  bed, 
adenoid  vegetations,  headache,  chronic  constipation,  and 
meteorism. 


i40  DISEASES  OF  THE  THYMUS  GLAND 

Fig.  48. — Mild  type  of  myxedema  with  a  moderate  degree  of  imbecil- 
ity. Five-year-old  girl.  Stupid,  anxious  expression  of  face,  a  heavy 
appearance  about  the  lower  jaw ;  double  chin  ;  short  neck  ;  broad  chest. 
The  skin  felt  hard,  dry,  and  was  thickened.  The  thyroid  gland  was  not 
palpable  ;  all  movements  were  somewhat  stiff. 

Fia.  50. — Pronounced  infantile  myxedema.  Girl  of  six  and  a  half 
years.  A  uniform  tense  swelling  of  the  skin  of  the  whole  bo<ly ;  dull 
expre.<«5ion  of  face.  Eyes  small  and  deeply  set;  nose  but  slightly  ele- 
vated ;  lips  swollen ;  a  thick,  short  neck ;  double  chin ;  protruding 
breasts;  thick  hands  and  arms;  mild  genu  valgum.  Excerpts  from 
patient's  history  :  Increase  in  weight  since  the  second  year  of  life  ;  cessa- 
tion in  longitudinal  growth  during  the  fourth  year.  At  that  time  the 
weight  was  20.8  kg.  [44  lbs]  (normal,  19.5kg.  [42.9  lbs.]);  length,  92.7 
cm.  [37.4  in.]  (normal,  105cm.  [42  in.]).     (Clinic  of  Escherich,  Vienna.) 

Fig.  51. — The  same  girl  after  three  months'  treatment  with  a  fresh 
preparation  of  the  thyroid  gland.  Length,  95.5  cm.  [38.2  in.]  ;  weight, 
16.7  kg.  [36.7  lbs.].  (Note  the  change  in  expression  in  the  eyes,  the  nose, 
mouth,  neck,  chest,  waist,  and  upper  and  lower  extremities.) 

Fig.  52. — Myxidiotie.  Symptoms  of  myxedema  and  idiocy.  (Clinic 
of  Escherich,  Vienna.) 

Fig.  53. — Myxidiotie.  A  pronounced  case  of  myxedema  with  fully 
developed  idiocy.  Six-year-old  girl.  I..ength,  78  cm.  [31.4  in.]  (normal, 
102  cm.  [40.8  in.]).  The  thyroid  gland  is  absent.  Specific  treatment  was 
refused  by  the  mother. 

Infantile  msrzedema  represents  the  true  myxedema  of 
adult  life.  The  skin  is  pale,  thickened,  dry,  stretched, 
and  usually  cool ;  the  eyelids  are  swollen  and  the  face  is 
muddy.  The  lips  and  tongue  are  thickened  ;  chronic 
constipation  ;  di.stended  abdomen  ;  dry,  brittle  hair,  which 
has  a  tendency  to  fall  out;  a  chilly  feeling  is  pronounced. 
The  disposition  is  apathetic  and  peevish.  The  facial 
expression  is  immobile  and  slightly  stupid  ;  slowness  of 
speech  and  movement ;  diminished  longitudinal  growth ; 
increased  body  weight. 

Myxidiotie,  Sporadic  Cretinism,  Infantilism. — The  symp- 
toms of  myxedema  together  with  an  enlarged  protruding 
tongue ;  flowing  of  the  saliva  from  the  mouth  ;  a  silly  and 
dull  facial  expression  ;  j)lump,  short  extremities  ;  varying 
grade  of  idiocy  ;  interference  with  longitudinal  growth 
resulting  in  dwarfism.  In  the  majority  of  cases  of  hypo- 
thyroidism the  Rontgen-ray  photograph  demonstrates  a 
retardation  of  ossification  in  the  skeleton  of  the  hand. 


Fig.  48. 


141 


142  DISEASES  OF  THE  THYMUS  GLAXD 


Fk;.  50. 


Fig.  51. 


t 


f 


Fig.  52. 


143 


144  DISEASES  OF  THE  THYMUS  GLANb 


FiG.  b6. 


HYPOTHYROIDISM.   D YSTHYROIDISM 


145 


The  course  is  chronic  in  all  forms  of  hypothyroidism  ; 
which  with  the  cessation  of  treatment  may  disapj)ear  or 
even  continue  for  a  long  time.  If  the  skiagram  demon- 
strates the  presence  of  the  intermediary  cartilaginous 
plate  on  the  epiphyses  of  the  hand,  it  may  be  considered 
a  favorable  sign. 

Fetal  Myxedema. — (See  p.  136.) 


i^/\ 


X 


Fi(i.  51.  — lijfautilc  obesity.     (Clinic  of  Escherich,  Vienna.) 

Treatment  of  Hypothyroidism. — This   disease  responds 
most  satisfactorily  to  the  specific  treatment,  which  con- 
sists in  the  administration  of  from  0.05  to  0.2  gm.  or 
0.3  gm.  of  thyroidin  (Merck;  Burroughs  and  Welcome). 
10 


146        HEMORRHAGIC  DIATHESIS.     PURPURA 

Begin  cautiously  with  small  doses,  and  stop  its  use  when 
cardiac  palpitation,  restlessness,  fever,  and  albuminuria 
arise.  This  treatment  should  continue  throughout  life. 
Warm  baths  and  hot  packs  should  be  frequently  resorted 
to. 

OBESITY 

This  rarely  occurs  in  children  ;  it  is  either  congenital 
or  due  to  improper  feeding.  In  nursing  infants  it  is  fre- 
quently rapid  in  development.  If  of  the  anemic  tyjse 
there  is  pallor  of  the  face  and  of  the  mucous  membranes ; 
the  pulse  is  small  and  there  is  a  tendency  to  become  easily 
fatigued.  In  the  plethoric  type  the  face  is  fresh  and  red 
in  appearance,  the  pulse  is  full,  the  musculature  strong, 
and  the  temperament  phlegmatic.  In  nursing  children  the 
course  is  chronic  and  there  is  danger  from  the  lack  of 
resistance  against  intercurrent  infections. 

Treatment. — Reduction  of  fats  and  carbohydrates; 
active  and  passive  motion ;    massage. 

HEMORRHAGIC  DIATHESIS.     PURPURA 

These  two  conditions  are  associated  because  of  the  fol- 
lowing symptoms  which  they  possess  in  common  :  They 
develop  as  independent  diseases  accompanied  by  hemor- 
rhages in  the  skin  and  mucous  and  serous  membranes. 
Their  etiology  is  unknown.  Each  individual  form  repre- 
sents but  slight  differences  of  the  same  disease  process. 

SIMPLE    PURPURA 

Hemorrhages  occur  only  in  the  skin  as  isolated  groups, 
about  the  size  of  a  pin's  head  or,  at  the  most,  the  size  of  a 
lentil.  Then  eruption  begins  in  the  legs  and  travels  up- 
ward in  groups.  The  general  health  is  but  slightly  dis- 
turbed. There  is  no  fever,  but  weakness  and  depression 
exist.  The  eruption  disappears,  but  frequently  tends  to 
recur.  Complete  recovery  may  be  expected  in  a  few 
weeks. 


HEMORRHAGIC  PURPURA  147 

RHEUMATIC  PURPURA  (PELIOSIS) 

This  is  accompanied  by  an  eruption  of  dark  red  spots 
on  the  legs  and  feet,  abdomen,  arms,  and  genitalia,  and 
particularly  also  on  the  knee-,  ankle-,  and  elbow-joints. 
The  aifeeted  joints  are  swollen  and  painful;  the  tibia, 
small  bones,  and  other  bones  are  also  frequently  sensitive. 
There  is  weakness  and  loss  of  appetite.  Fever  is  often 
absent  or,  if  present,  is  but  slight.  The  course  is  pro- 
longed throughout  a  number  of  weeks  on  account  of  the 
tendency  to  frequent  reappearance  of  the  eruption. 

HEMORRHAGIC  PURPURA  (MORBUS  MACULOSUS 
WERLHOFIl) 

In  this  disease  hemorrhages  occur  not  only  in  the  skin 
but  also  in  the  mucous  membranes  and  in  the  internal 
organs.  Dark  red  spots,  varying  in  size  from  that  of  a 
lentil  to  that  of  a  pigeon's  egg,  which  do  not  disappear 
on  pressure,  are  found  on  the  skin  of  the  extremities  and 
of  the  trunk  ;  pea-sized  hemorrhages  occur  on  the  mucous 
membnine  of  the  mouth,  nose,  and  in  the  conjunctiva. 
Occasionally  there  is  also  hematuria,  bloody  stools,  vomit- 
ing of  blood,  rarely  bloody  expectoration,  and  retinal  or 
meningeal  hemorrhages.  The  disease  begins  with  a  vague 
feeling  of  ill  health,  followed,  as  a  rule,  by  a  sudden  erup- 
tion and  extension  of  spots  over  the  whole  body  within 
twenty-four  hours.  These  become  confluent  and  lead 
to  large  extravasations,  gradually  changing  to  a  brownish- 
red  or  dark  blue  color.  There  is  considerable  disturbance 
in  the  general  health,  weakness,  headache,  and  articular 
pains;  decided  anemia;  slight  fever  and  slow  pulse. 

Course. — The  symptoms  recede  within  two  or  three 
weeks  and  the  })atient  gradually  passes  into  convalescence. 
Relapses  are  common.  There  is  danger  of  continued 
hemorrhages,  leading  to  severe  anemia  and  weakness. 
The  prognosis  is,  therefore,  not  absolutely  favorable. 

ABDOMINAL   (HENOCH'S)    PURPURA 

To  the  symptoms  of  rheumatic  purpura  are  added  com- 
plex abdominal  ])henoraena :  vomiting,  colic,  and  intes- 


148         HEMORRHAGIC  DIATHESIS.      PURPURA 

PLATE  lo 

Purpura  Hemorrliaglca. — The  disease  in  a  nine-year-old  boy  ran  the 
course  of  Henoch's  purpura,  accojiipanied  by  severe  gastro-intostinal 
symptoms.  It  began  with  fever  and  painful  swelling  of  the  left  knee- 
joint.  On  the  following  day  an  eruption  appeared  in  the  neighborhood 
of  both  knees,  consisting  of  a  large  number  of  red  spots,  varying  in  size 
from  that  of  a  lentil  to  that  of  a  cherry,  which  failed  to  disappear  on 
pressure.  A  similar  eruption  gradually  appeared  on  the  elbows,  nates, 
scrotum,  and  penis,  while  all  visible  mucous  membranes  remained  free. 
The  fifth  day  of  the  disease  was  followed  by  almost  constant  vomiting, 
severe  colicky  pains,  bloody  stools,  and  rapid  decline.  Ice,  opium,  and 
ergotin  remained  ineffectual.  Injections  of  O.OOO.i.grn.  of  atropin  (three 
in  all)  led  to  immediate  improvement  and  to  a  permanent  relief  of  the 
intestinal  symptoms.  The  hemorrhages  of  the  skin  recurred  but  twice 
during  the  course  of  the  next  year. 

tinal  liemorrhage,  the  intensity  of  wliich  causes  them  to 
predominate.  The  attacks  occur  gradually  in  s})ells  at 
intervals  of  several  days,  weeks,  or  even  a  year.  The 
vomiting  is  very  obstinate  and  controlled  with  difficulty, 
the  colic  is  extremely  painful  and  deprives  the  j)atient  of 
sleep  (children  lie  in  bed  groaning  and  twisting  about). 
The  stools  contain  either  fresh  blood  or  they  are  discolored 
black  and  sometimes  orange  colored.  The  general  health 
is  decidedly  affected  and  there  is  loss  of  strength  on  ac- 
count of  the  hemorrhages  and  the  inability  to  take  food. 
The  course  is  protracted,  but  usually  favorable. 

FULMINATING    PURPURA 

Hemorrhages  of  the  mucous  membranes  are  absent. 
Extensive  ecchymoses  develop,  which  lead  with  enormous 
rapidity  in  a  few  hours  to  hemorrhagic  infiltration  and 
dark  blue  discoloration  of  the  whole  extremities.  Death 
follows  in  from  one  to  four  days. 

TREATMENT   OF    PURPURA 

Rest  in  bed  is  necessary  in  all  forms  (including  the 
mild  ty|>es),  as  is  also  a  non-irritating  diet — milk,  infant 
foods,  meat-soups,  eggs,  chopped  meat,  tender  vegetables, 
raw  fruit  juices,  and  fresh  fruit.  Acid  drink.s,  citric  or 
phosphoric  acid,  are  of  value.  If  hemorrhages  occur,  a 
1   per  cent,  solution  of  ergotin  or  fluidextract  of  ergot 


7ab.. 


y 


I 


*^'\  % 


ANEMIA  149 

may  be  used.     Also  the  powdered  extract  of  the  supra- 
renal gland  or  adrenalin. 

In  case  of  rheumatic  purpura,  immobilize  the  joints  and 
apply  ichthyol  dressings  ;  internally  give  sodium  salicylate 
or  aspirin.  In  abdominal  purpura  a  strict  dietary  must 
be  followed  :  Ice,  ice-water,  iced  milk,  milk  of  almonds, 
ice-bag  to  the  abdomen  ;  injections  of  atropin  sulphate  in 
from  ^  to  ^  mg.  doses  [1  to  5  per  cent,  solutions  may  be 
given  internally  with  advantage]  ;  gelatin  injections  ;  less 
certain  than  these  in  action  is  0.05  gm.  of  the  extract  of 
opium  in  120  gm.  of  the  emulsion  of  amygdala. 

ANEMIA 

Condition  of  the  Blood. — Diminished  amount  of  hemo- 
globin and  a  decrease  in  the  number  of  red  blood-cells 
(oligochromemia  and  oligocythemia).  Poikilocytosis ;  leu- 
kocytes unaltered. 

Etiology. — Simple  anemias  are  most  often  secondary, 
following  chronic  and  severe  acute  diseases,  especially 
tuberculosis,  syphilis,  rachitis,  gastro-intestinal  diseases, 
intestinal  worms,  chronic  kidney  and  heart  disease,  pleu- 
ritis,  pneumonia,  etc.  Other  powerful  factors  are  unsuit- 
able food,  damp,  overcrowded  dwellings,  attending  sclux)! 
(school  disease),  and  premature  and  excessive  hardening 
processes.  Anemia  occurs  at  any  age,  but  it  is  especially 
frequent  in  the  first  two  years  of  life  and  the  years  pre- 
ceding puberty. 

Symptoms. — Pale  and  somewhat  dry  skin  and  pale 
mucous  membranes ;  certain  constitutional  phenomena ; 
weakness,  easily  fatigued,  irritability  and  rapidly  change- 
able disposition,  headache,  and  constipation.  Blowing 
anemic  murmurs,  chiefly  over  the  pulmonic  area,  venous 
hums  (apply  stethoscope  lightly,  as  tight  pressure  alone 
may  create  murmurs). 

Pernicious  anemia  is  very  rare  in  childhood.  The 
blood  shows  the  changes  incident  to  anemia  together  with 
raegalocytes  and  megaloblasts.  Symptoms  and  course  as 
in  adults. 


150  CHLOROSIS 

CHLOROSIS 

Condition  of  Blood. — Diminution  in  the  amount  of 
hemoglobin  (oligochromemia),  without  a  decrease  in  the 
number  of  red  blood-cells.  There  is  a  noticeable  dif- 
ference in  the  size  of  the  latter,  there  being  many  macro- 
and  microcytes.  The  white  blood-corpuscles  show  no 
characteristic  changes. 

Etiology. — The  blood-building  organs  are  less  active. 
Predisposing  factors  are :  Unfavorable  conditions  of 
dwellings  and  feeding,  wearing  of  corsets,  premature 
difficult  physical  or  mental  work,  and  insufficient  sleep. 
The  disease  chiefly  attacks  girls  before  and  after  the 
period  of  puberty,  yet  it  is  sometimes  found  in  boys. 

Symptoms. — A  pale  to  pale-green  color  of  the  skin  ; 
pale  mucous  membranes.  Adipose  tissue  well  preserved. 
Slight  edema  of  the  knuckles.  An  unusual  degree  of 
weariness  and  desire  to  sleep ;  dyspnea  ;  loss  of  appetite, 
with  a  special  dislike  for  meat.  Irritability,  headache, 
vertigo,  ringing  in  the  ears,  and  painful  sensations  in  the 
region  of  the  stomach  and  the  ribs.  Enlargement  of  the 
cardiac  dulness  to  the  right.  Blowing  murmurs  of  vary- 
ing intensity  at  the  apex  of  the  heart  and  in  the  pulmonic 
area;  venous  murmurs  in  the  right  side  of  the  neck.  In 
the  diagnosis  we  must  exclude  secondary  anemia,  espe- 
cially tuberculosis,  gastric  ulcer,  and  intestinal  worms. 

TREATMENT  OF  ANEMIA  AND  CHLOROSIS 

The  cause  must  be  eliminated.  At  the  beginning  the 
patient  should  receive  much  rest  and  sleep  or  indulge  in 
a  rest-cure  lasting  several  weeks.  Exercise  in  the  open 
air  is  to  be  postponed  until  later.  Protect  against  heat 
dissipation  by  careful  selection  of  clothing;  no  cold-water 
procedures  without  supervision. 

Feeding. — For  nurslings  give  raw  or  slightly  boiled 
milk,  and  adopt  a  mixed  diet  early  in  life.  In  case  of 
older  children  exclude  coarse,  indigestible  food  and  give 
pressed  meat  juice,  chopped  meat,  iron-containing  vege- 
tables, green  lettuce  with  oil  and  lemon,  raw  or  cooked 
fruits,  and  good  cows'   or  goats'  milk.     Vary  the   diet 


SPLENIC  ANEMIA  151 

as  much  as  possible.  Stimulate  tjie  appetite  with  puree 
of  meat  juice,  caviar,  sardines,  etc.  (all  in  small  quantities). 
Medication  includes  the  compound  tincture  of  cinchona 
or  wine  of  iron  and  quinin  (6  to  10  drops  of  the  former 
and  a  coffeespoonful  of  tlie  latter  before  or  after  meals). 
[The  albuminates  of  iron — although  for  the  most  part 
proprietary  remedies — are  best  adapted  for  administration 
to  children.  They  do  not  injure  the  teeth  and  are  well 
tolerated  by  the  stomach.  This  class  is  represented  by 
the  peptomanganates,  hematogen,  etc. — Ed.] 

Hydrotherapy. — Older  children  are  treated  with  heat 
bv  the  application  of  hot  packs  to  the  whole  body ;  hot 
baths  (37°  to  38°  C.  [98.6°-100.4°  F.])  or  vapor  baths, 
followed  by  a  short  cold-water  bath  (be  cautious  in  case 
of  delicate  children).  Follow  by  rest  in  bed,  rub  down 
with  brandy  or  eau  de  Cologne  ;  massage.  It  is  best  to 
resort  to  these  various  procedures  in  regular  rotation  with 
days  of  rest  intervening.  All  procedures  should  cease  in 
from  four  to  six  weeks.  Short  air-baths  in  the  room 
with  exercise ;  sun-baths  in  midsummer.  In  severe 
cases  give  arsenic  with  iron  (4.0  gm.  of  Fowler's  solution 
added  to  liquor  ferri  albuminatus  20.0  gm. ;  give  of  this 
from  2  to  8  or  15  drops  three  times  a  day  in  slowly  in- 
creasing and  likewise  decreasing  doses).  Sojourn  in  the 
country  at  sunny  resorts ;  high  altitudes ;  bathing  resorts. 

SPLENIC  ANEMIA:    INFANTILE  PSEUDO- 
LEUKEMIA 

Condition  of  the  Blood. — Diminution  of  hemoglobin 
and  of  the  number  of  red  blood-cells  ;  nucleated  erythro- 
cytes; slight  leukocytosis;  occasionally  megaloblasts. 

Symptoms. — The  various  phenomena  of  anemia  ac- 
companied by  a  protruding  abdomen,  enlarged  spleen 
(which  is  palpable  as  a  hard,  non-painful  movable  tumor), 
and  enlarged  liver;  the  cervical  glands  are  swollen.  It 
runs  a  varied  course  with  gradually  increasing  cachexia ; 
cure  is  possible,  but  rare. 

Treatment. — Arsenic  with  iron  or  injections  of  arsenic. 
(For  other  details  of  treatment,  see  Anemia.) 


CHRONIC   INFECTIOUS  DISEASES 

HEREDITARY  OR  CONGENITAL  SYPHILIS: 
HERED0SYPHILI5 

Transmission. — The  infection  occurs  in  all  cases  before 
birth,  and  is  usually  transmitted  from  the  father  by  the 
introduction  of  the  virus  into  the  ovum  simultaneously 
with  its  union  with  the  spermatozoon  ;  in  this  case  the 
mother  remains  healthy.  More  rarely  the  infection 
originates  in  the  mother  if  she  is  a  syphilitic  before  she 
becomes  pregnant,  when  the  poison  travels  through  the  pla- 
centa ;  a  purely  ovular  infection  has  not  been  demonstrated. 

The  transmission  of  the  virus  from  infection  during 
pregnancy  is  exceptional,  and  is  only  possible  by  involve- 
ment of  the  maternal  and  fetal  placenta. 

If  both  parents  ai'e  syphilitic,  the  disease  can  neverthe- 
less be  transmitted  from  only  one  parent,  for  the  pre- 
viously infected  germinal  cell  is  immune  against  a  second 
infection. 

The  inheritance  is  facultative  and  depends  upon  the 
fact  that  either  the  spermatozoon  or  the  ovum  contain 
the  syphilitic  poison.  This  explains  the  possibility  of 
parents  who  recently  had  syphilis  giving  birth  to  healthy 
children  (Finger).  The  more  recent  the  infection  of  the 
parents,  the  greater  and  the  prompter  in  appearance  is 
the  infection  in  the  child  (Finger). 

The  poison  tends  gradually  to  lose  its  virulence  in  the 
parental  organism,  so  that  in  an  almost  regular  order  of 
rotation  the  mother  gives  birth  to  miscarriages,  premature 
births,  full-term  dead  infants,  children  which  at  first  live 
for  but  a  short  time,  and  later  such  as  live  a  longer  time, 
and  finally,  healthy  children.  This  order  may  be  inter- 
rupted by  the  birth  of  perfectly  healthy  children. 

A  syphilitic  child  which  has  been  infected  by  its  father 
cannot  transmit   the  virus  to  the  mother,  for  she  became 
immune  during  pregnancy  (Colles'  law).     (Exceptions  to 
this  rule  are,  however,  met  with.) 
152 


HEREDITARY  OR  CONGENITAL  SYPHILIS       153 

Clinical  Symptoms. — The  child  is  either  born  with  the 
signs  of  syphilis,  or  they  do  not  appear  until  after  a  latent 
period  of  from  several  days  to  months.  The  earliest 
phenomena  are : 

Snujfics. — Swelling  of  the  nasal  mucous  membrane, 
which  is  accompanied  at  first  by  a  dry,  and  later  by  a 
dirty  ])us-like  and  bloody  secretion,  causing  a  peculiar 
sniffing  noise  called  the  "  snuffles  "  ;  not  until  later  are 
rales  also  heard.  Desiccation  and  maceration  of  the 
secretion  causes  the  formation  of  brownish  crusts  or 
excoriations  at  the  nasal  orifices.  Extension  of  the 
ulcerative  process  to  the  cartilaginous  and  bony  portion 
leads  to  development  of  the  saddle-nose.  The  coryza  is 
the  most  constant,  earliest,  and  most  obstinate  sign  of 
hereditary  syphilis ;  it  may  exist  at  birth,  and  outlasts, 
as  a  rule,  all  other  signs. 

Pemphigus,  or  Bullous  Syphilid  (see  Plate  42). — These 
are  soft  vesicles,  varying  in  size  from  a  lentil  to  a  cherry, 
which  occur  on  all  parts  of  the  body,  and  especially  on 
the  palms  of  the  hands  and  the  soles  of  the  feet.  They 
may  be  present  at  birth  or  appear  during  the  first  three  or 
four  days.  (For  Diiferentiation  from  Pemphigus  Vul- 
garis, see  p.  166.) 

Enlargement  of  the  spleen  and  liver  may  occur  as  prom- 
inent signs  of  fetal  visceral  syphilis  during  the  nursing 
period.  An  abnormal  lack  of  weight  and  longitudinal 
growth  are  usually  noticeable  at  birth.  Atrophy  and 
anemia  are  frequent,  but  not  always  present.  The 
following  are  some  of  the  symptoms,  which  do  not,  as  a 
rule,  appear  until  several  weeks  have  elapsed  : 

The  Skin. — The  Macular  and  Papular  Squamous  Si/ph- 
ilid. — These  are  brownish-red,  lentil-  or  mustard-seed- 
sized  sjiecks,  which  are  especially  likely  to  occur  on  the 
eyebrows,  chin,  nasolabial  folds,  soles,  and  the  palms. 
The  sjx)ts  are  considerably  elevated  and  show  a  tendency 
to  exfoliate  and  form  crusts.  A  papular  efflorescence  is 
especially  likely  to  occur  in  the  anal  and  genital  regions. 
Macenition  of  the  secretion  causes  the  development  of 
multiple  fissured  and  weeping  excoriations  at  the  angles 


154  CHR02iIC  INFECTIOUS  DISEASES 

of  the  mouth  and  at  the  anus.  In  .addition  to  these 
specific  exanthems  we  also  meet  with  eczematous  and 
psoriasis-like  varieties. 

Diffuse  S]/phi/itic  InjUtration  of  the  Skin  (Hochsinger). 
— The  skin  of  the  palms,  the  soles,  nates,  genitalia,  and 
folds  of  the  groin  are  decidedly  red,  dense,  thickened, 
and  shiny,  as  if  varnished.  That  of  the  face  is  tense  and 
gives  a  mask-like  appearance.  Splitting  of  the  stretched 
skin  causes  the  formation  of  fatty  rhagades  covered  with 
crusts,  which  radiate  from  the  edge  of  the  lips  to  the  nose 
and  chin  ;  later  they  become  converted  into  scar-tissue, 
which  remains  visible  for  many  years.  Paronychia  fol- 
lows infiltration  of  the  matrix  of  the  nails.  The  charac- 
teristic loss  of  hair  from  the  scalp  and  eyebrows  depends 
likewise  upon  a  diffuse  infiltration  of  the  involved  areas 
of  the  skin.  The  skin  usually  has  a  livid  and  at  times 
dirty  yellow  and  slightly  shiny  color  [Trousseau's  color]. 
The  associated  hemorrhages  in  the  skin  and  mucous  mem- 
branes (see  Hemorrhagic  Syphilis)  are  caused  by  a  septic 
infection,  which  usually  extends  from  the  umbilicus. 

Liver. — Children  in  whom  the  syphilitic  symptoms  are 
not  very  pronounced  develop  icterus  in  the  course  of  two 
or  three  months,  accompanied  by  bile  in  the  urine  and 
acholic  stools ;  there  is  also  an  enlarged  and  resistant 
liver,  sj)lenic  tumor,  and  ascites. 

Kidneys. — Involvement  of  the  kidneys  is  manifested 
(chiefly  at  the  close  of  life)  in  the  form  of  an  ordinary 
acute  nephritis  with  albumin  and  granular  casts;  or  as  a 
true  hemorrhagic  inflammation. 

Lymph-nodes. — Swelling  of  the  lymph-nodes,  espe- 
cially in  the  cervical,  axillary,  cubital,  and  inguinal 
regions,  is  rarely  present.  [Swelling  of  the  cervical 
lymph-nodes  (wcurs  if  there  be  an  ulcerating  lesion  in  the 
mouth,  nose,  etc. — En.] 

Bones. — Painful,  pale,  ring-shaj)ed  swelling  of  one  of 
the  lower  epiphyses  of  the  humerus  or  femur.  This  is 
accompanied  by  a  slight  "voluntary"  paral^'sis  of  the 
affected  side,  without  the  signs  of  degeneration  and  with- 
out involvement  of  the  joint — Parrot's  pseudoparalysis. 


HEREDITARY  OR  CONGENITAL  SYPHILIS       155 

Syphilitic  Phalangitis  (Hochsinger). — This  consists  of  a 
painless  swelling,  primarily  of  the  first  phalanges,  sec- 
ondarily of  the  middle  and  distal  phalanges  of  the  fingers 
and  toes,  which  causes  the  former  to  assume  the  sha})e  of 
a  bottle,  the  latter  the  shape  of  a  tenpin.  There  is  no 
tendency  for  the  swelling  to  rupture  externally  or  to  in- 
volve the  soft  parts.     Both  affections  of  the  bones  are 


Fig.  55. — Parrot's  pseiidoparaly.si.s  of  ihe  left  forearm  and  the  hand 
in  hereditary  s.yphilis.  Child  four  months  old.  Specific  loss  of  hair 
from  the  scalp,  eyebrows,  and  eyelashes.  (A  maculopapular  exanthem 
had  disapi)eared,  but  the  splenic  tumor  and  coryza  still  persisted.) 
(Clinic  of  von  Ranke,  Munich.) 

caused  by  an  osseous  inflammation  which  has  spread  from 
the  zone   betwx'cn   the  cartilage  and  bono  (see  Pathologic 
Anatomy).     Syphilitic  paralyses  without  involvement  of 
the  bones  are  due  to  a  gumma  or  arteritis  of  the  brain. 
These  processes  present  the  symptoms  of  paralysis  of 


156  CHRONIC  INFECTIOUS  DISEASES 

PLATE   II 

Papular  Rash  of  the  Nates  and  LahlaMaJora  in  Hereditary  Syphilis. 
— This  girl  (seven  and  a  half  months  old)  ]>icsents  on  tlie  skin  of  tlie 
labia  mjyora  and  in  the  region  of  the  anus  a  large  number  of  efflorescent 
papules.  These  are  twice  the  size  of  a  lentil,  pale  blue  in  color,  umbili- 
cated,  and  excrete  a  slight  discharge.  This  rash  is  accompanied  by  a 
non-specific  eczema  with  dark  red,  elevated,  and  vesicular  i)apules,  which 
are  also  efflorescent  (Eczema  erythematosum,  papulosum,  and  vesicu- 
losum).  Other  symptoms  manifested  in  this  case  were  a  pale-yellow, 
slightly  shiny  skin,  splenic  tumor,  and  saddle-nose.  Cure  iu  six  weeks 
by  means  of  iodid  of  mercury. 

the  upjior  and  lower  plexuses  of  nerves,  and  also  prob- 
ably play  an  important  part  in  many  cases  of  Little's  dis- 
ease, polio-encephalitis,  idiocy,  congenital  hydrocephalus, 
etc.  Occasionally  specific  infiltrations  and  ulcers  are 
found  in  the  larynx,  intestines,  testes,  and  various  other 
organs. 

Sjrpliilis  Tarda. — Children  whose  parents  have  undoubt- 
edly had  syphilis  occasionally  develoj),  after  the  fifth  year 
of  life,  certain  phenomena  which  conform  exactly  with 
the  tertiary  manifestations  of  acquired  syphilis.  It  has 
not  yet  been  determined  whether  we  have  to  do  in  that 
case  with  delayed  manifestations  of  a  case  of  true  hered- 
itary syphilis,  with  the  continuation  of  an  overlooked 
early  syphilis,  or  with  the  tertiary  stage  of  syphilis 
acquired  in  early  life. 

Chief  Symptoms. — Periostitis  of  the  hyperplastic,  gum- 
matous, and  ulcerative  tyi^e.  As  a  result  of  this  process 
we  have  chiefly  a  painful  scabbard-like  swelling  of  the 
tibia  and  the  formation  of  the  saddle-no.se.  A  tor- 
pid, usually  symmetric  swelling  of  the  knee-joints, 
which  causes  ankylosis.  Gummata  occur  in  the  .skin 
of  the  face  and  on  the  legs,  arranged  iu  groups,  which 
heal  slowly ;  also  in  the  mucous  meml)ranes,  especially 
in  the  mouth,  where  they  undergo  radiating  cicatri- 
zation ;  perforation  of  the  palate  ;  cicatricial  stenoses  in 
the  larynx. 

Indolent  swellings  of  the  lymph-nodes  of  the  cervical, 
axillary,  cubital,  and  inguinal  regions.  There  is  fre- 
quently considerable  swelling  of  the  liver  and  spleen,  and, 
notwithstanding  the  absence  of  other  pronounced  synip- 


^ 


■«<a|ip««pi«>M^*i 


HEREDITARY  OR  CONGENITAL  SYPHILIS        157 

toms,  the  patient  frequently  suffers   from   a   contracted 
kidney. 


*^ 


^'vV 


< 


Fig.  56. — Crater-like  ulceration  of  the  hone  hrought  on  hy  pnm- 
matous  and  ulcerating  periostitis  and  osteitis;  congenital  syphilis 
(relapse).  Child  one  and  a  half  years  old.  (Preparation  from  the 
Munich  Pathologic  Institute.) 

Involvement  of  the  Nervous  System. — Headache,  various 
forms  of  paralysis,  infantile  tabes,  ]>rogrcssive  paralysis, 
idiocy,  etc.,  are  caused  by  chronic  endarteritis  with  local 


158  CHRONIC  INFECTIOUS  DISEASES 

PLATE   12 

Fig.  1.  Diphtheria  of  the  Uvula.— Enlarged  300  times.  1.  Swollen 
epithelium.  2.  Vesicular  spaces  in  epithelium.  3.  Leukocytes.  4.  Fibriu. 
5.  Nuclei  of  the  destroyed  epithelium  in  fibrin.  (From  Diirck,  Atlaa 
of  General  Patholofiic  Histology.) 

Fig.  2.  Syphilitic  Infiltration  of  the  Liver  in  a  Congenltally  Syphil- 
itic Eight-months'  Old  Fetus,  which  was  Dead  when  Born.-^Enlarged 
50  times.  Beginning  maceration.  1.  Foci  of  small-cell  infiltration, 
which  are  beginning  to  form  a  gumma.  2.  Proliferation  of  hepatic 
parenchyma  cells.  3.  Thickening  of  the  capsule  of  Glissou.  4.  En- 
larged bile-ducts. 


areas  of  softening,  chronic  meningitis,  and  cerebral 
guraraa. 

Of  the  so-called  "  Hutchinson's  triad" — interstitial 
keratitis,  central  deafness,  and  peculiar  deformity  of  the 
teeth — only  the  first  is  of  pathognomonic  value.  The 
second  is  rare  and  occurs  also  in  other  affections ;  like- 
wise the  third,  the  median  excavation  of  the  upper 
inner  permanent  incisor  teeth. 

Recurrence. — In  about  one-third  of  the  cases  apparent 
cure  is  followed  within  the  first  four  years  by  one  or 
several  relapses  of  this  disease.  The  recurrence  repre- 
sents either  a  mild  form  of  the  first  attack  with  maculo- 
papular  exanthem,  corvza,  rhagades,  etc.,  or  multijile 
weeping  mucous  papule.',  broad  condylomata  at  the  anus, 
genitalia,  and  oral  cavity — the  condylomatous  stage  of 
hereditary  syphilis.  The  latter  is  accompanied  by  deep 
gummatous  disease  of  the  bones,  the  skin  of  the  ex- 
tremities, and  of  the  skull ;  the  liver,  spleen,  kidneys, 
pancreas,  and  testes ;  and  endarteritic  processes  in  the 
brain  and  spinal  cord,  together  with  polio-encephalitic, 
hemiplegic,  and  epileptic  manifestations  ;  iritis  and  local- 
ized chorioretinitis.  (See  Haab,  Atlas  of  Ophthalmoseopy, 
Plates  39-41.) 

Morbid  Anatomy. — Macrosco]>ic  changes  do  not  set  in 
until  after  the  fourth  fetal  month,  and  from  the  fourth  to 
the  sixth  month  the  chief  changes  consist  in  an  osteo- 
chondritis and  an  enlarged  spleen.  The  whole  chain  of 
the  remaining  manifestations  do  not  appear  until  later. 
The  post-mortem  examination  is  not  infrequently  nega- 


m^y 


I 


r^^. 


A  :  «■       ^ 


j?y9:i. 


HEREDITARY  OR   CONGENITAL  SYPHILIS       159 


tive.  The  macerated  "  sangu indent "  condition  of  the 
fetal  corpse  })resents  in  itself  no  characteristic  change. 
Even  children  Avho  during  life  showed  the  undoubted 
presence  of  syphilis,  frequently  fliil  after  death  to  present 
any  of  the  positive  symptoms  of  that  disease. 


Fig.  57. — Normal  thymus  of  a  healthy  full-term  child  which  died 
duriufj  birth.  The  oigau  is  richly  supplied  with  cellular  tissue,  but 
sparsely  with  thin  connective-tissue  septa.  Enlarged  52  times.  1.  Per- 
ipheral substance.  2.  Marrow.  3.  Connective-tissue  septum.  4.  Hassal's 
corpuscles. 

The  most  important  (7ro.9S  anatomic  changes  are:  En- 
largement, induration,  and  increase  in  weight  of  the  large 
abdominal  glands  ;  thus  the  spleen  weighs  ^^  to  3^^^  of 
tiie  body  weight  in  comparison  with  ^^^  normally ;  the 
liver,  ^-^  instead  of  ^Y,  and  the  kidney,  -^  instead  of  y^j. 
The  weights  only  hold  true  for  fetal  syphilis  and  that  of 
the  early  nursing  period.  Later  the  organs  undergo 
atrophy  under  the  influence  of  tlie  cachexia,  and  hence 
lose   in    weight.     An   exce|)tion   to  this  is  the  thymus, 


160  CHRONIC  INFECTIOUS  DISEASES 

PLATE  13 

Syphilitic  Changes  in  the  Kidneys  of  a  Stillhom  Congenital  Syph- 
ilitic (eight  to  nine  months). — Magnified  42  times.  Beginning  mucerar 
tion.  1.  Thickened  and  partly  obliterated  peripheral  arteries,  whose 
walls  and  surrounding  tissues  show  small-cell  infiltration.  2.  Periviuscular 
small-cell  infiltration.  3.  The  cortex  is  increased  in  width  and  under- 
going retrogressive  development.    4.  Young  glomeruli. 


which  in  fetal  syphilis  weighs  almost  constantly  less  than 
normal,  on  an  average  3-}-^  of  the  body  weight  instead  of 
the  normal  -^^-g.  Also  note  that  aside  from  an  increase  in 
weight  the  liver  is  more  elastic  than  normal  (a  piece  held 
between  the  fingers  may  be  snapped  away  like  a  cherry 
stone) ;  it  is  dark  in  appearance,  and  on  cross-section  the 
surface  varies  from  a  brownish-violet  to  a  slightly  shiny 
yellow  color ;  the  capsule  is  thickened  and  opaque. 

Syphilitic  osteochondritis  is  the  most  frequent  of  the 
earliest  and  the  longest  in  duration  of  the  symptoms  of 
congenital  syphilis. 

Gummata  varying  in  size  from  a  miliary  tubercle  to 
that  of  a  hazel-nut,  as  well  as  overgrowtli  of  connective 
tissue  and  gross  cirrhotic  proces.ses,  are  found  in  all  the 
organs,  especially  the  liver,  spleen,  lung  (interstitial 
pneumonia),  pancreas,  thymus,  and  likewise  in  the  rose- 
red  discolored  placenta. 

Deserving  special  mention  is  the  so-called  "  white 
pneumonia  "  of  a  syphilitic  fetus,  in  which  the  enlarged 
firm  lung  appears  grayish  white  on  cross-section  ;  it  is 
generally  combined  with  the  interstitial  pneumonia.  An- 
other condition  to  be  referred  to  is  a  rare  cherry-sized 
abscess  of  the  thymus  (so  called  by  Dubois),  which  may 
be  easily  mistaken  for  the  normal  tissue  softening  in  the 
fetal  thymus. 

The  histologic  changes  of  hereditary  syphilis  are  uni- 
form in  so  far  as  the  chief  alterations  are  alike  in  every 
organ. 

Circumscribed  small-cell  infiltration,  especially  in  the 
neighborhood  of  the  large  blood-vessels,  which  has  a  tend- 
ency to  undergo  central  necrosis.  This  miliary  syphiloma 
may  be  regarded  as  the  beginning  stage  of  a  gumma  (see 
Plate  12,  Fig.  2). 


Tab. 


.  -.ja^iW^ 


jm^''- 


r*^. 


.^.0: 


V5 


.;  ;■& 


HEREDITARY  OR  CONGENITAL  SYVtllLIS      161 

Diffme  celluUir  infiltmtioii,  consisting  of  irregularly 
distributed  round  cells  throughout  the  whole  parenchyma. 

DIJf'me  and  cimtmscrihal  eonnedlrc-tlfi><iie  jtro/ifcration, 
representing  the  beginning  of  cirrhosis  (see  Plate  12, 
Fig.  2). 


Fio.  58. — The  thymus  gland  in  heredosyphilis  of  an  almost  full-term 
dead  child.  The  connective-tissue  septa  are  more  numerous  and  thick- 
ened ;  the  glandular  structure  is  shriveled  and  persists  only  in  certain 
areas  in  small  foci.  The  corpuscles  of  Hassal  lie  closely  crowded  together 
and  are  notably  large.  Magnified  52  times.  1.  Glandular  substance.  2. 
Connective-tissue  septa.    3.  Corpuscles  of  Hassal. 


Abnormal  epithelial  proliferation — collections  of  ejii- 
theliuni  in  the  liver  and,  rarely,  in  the  lungs  and  kid- 
neys. 

Individual  organs  are  especially  characterized  by 
certain  peculiarities  :  The  kidneys  of  the  fetus  show  cel- 
lular infiltration  of  the  walls  and  neighboring  structures 
11 


162  CHRONIC  INFECTIOUS  DISEASES 

of  the  smallest  i^eripheral  arteries,  enlargement  of  the 
epithelial  marginal  zone,  and  decrease  in  the  size  of  the 
glomeruli  (see  Plate  13);  nurslings  suffer  from  acute 
degenerative  nephritis.  The  spleen  undergoes  infiltra- 
tion of  the  middle  and  larger  sized  blood-vessel  sheaths. 
In  the  thymus  there  is  a  thickening  of  the  interlobular 
septa,  with  compression  and  shrinking  of  the  acini  (see 
Fig.  58).     The  alveoli  of  the  lungs,  which  are  the  seat 


/ 


1— 


1 

Fig.  59. — Umbilical  cord  of  a  healthy  newborn  chikl,  showing  unequal 
thickening  of  the  vessel  walls.  Magnified  11  times.  1.  Arteries.  2. 
Vein  with  thrombus. 

of  white  pneumonia,  are  filled  with  desquamated  and 
fatty  epithelium.  The  umbilical  cord  is  infiltrated  and 
the  venous  and  arterial  vessel  walls  are  thickened  almost 
sufficiently  to  cause  obliteration. 

Syphilitic  osteochondritis  (Wegner)  (see  Plate  12,  Fig. 
1),  which  attacks  chiefly  the  epiphyses  of  the  long  bones, 
is  marked  by  enlargement  of  the  provisional  zone  of 
calcification,  and  a  serrated  border  between  the  cartilage 


HEREDITARY  OR  CONGENITAL  SYPHILIS       163 


[■fiSir^i^^. 


Fig.  60. — Umbilical  cord  of  a  full-term  syphilitic  child  which  lived 
to  be  five  days  old.  Arteritis  and  phlebitis  obliterans.  The  walls  of  all 
three  vessels  are  considerably  thickened  ;  proliferation  of  the  intima. 
The  lumen  of  the  vein  is  much  reduced  in  size  ;  pus  iu  one  of  the 
arteries.     Magnified  11  times.     1.  Vein.     2.  Arteries. 


Fig.  61.— Umbilical  cord  of  a  syphilitic  newborn  infant.  Small-cell 
infiltration  of  the  media  of  both  arteries.  Magnified  8  times.  1.  Vein. 
2.  Arteries. 


164  CJIROMC  lyFECTlOUS  DISEASES 

and  bone ;  the  notches  of  this  border  when  palpated  are 
felt  to  be  hard  and  brittle.  The  bliiissh  and  swollen 
cartilaginous  zone  of  j)roliferation  is  diminished  in  size. 
Necrosis  rapidly  sets  in,  and  finally  there  is  inflammation, 
softening,  and  sequestration  of  the  calcified  and  insuf- 
ficiently nourished  tissue,  with  resulting  separation  of  the 
epiphysis. 


-iLiiw.'i^ti  »• 


Fig.  62. — Syphilitic  interstitial  pancreatitis  in  a  dead-born  infant 
from  seven  to  eight  months  of  age.  Enormous  growth  of  interstitial 
connective  tissue;  iuflamniatory  thickening  of  the  walls  of  the  blood- 
vessels and  excretory  ducts.  Magnified  25  times.  1.  Glandular  struc- 
ture, with  beginning  proliferation  of  interstitial  tissue.  2.  Prolifenvting 
interstitial  tissue.  3.  Rudimentary  glandular  substance.  4.  Thickened 
arteries.    5.  Thickened  excretory  ducts. 

Histologically  the  process  consists  of  a  hardening  (.see 
Plate  14,  Fig.  2,  and  Plate  6)  of  all  the  bone-building 
ti.ssues  (Heubner).  The  calcification  ])rogresses  in  an 
irregular  manner  into  the  cartilage,  involving  not  only  the 
cartilage  but  also  the  columns  of  cartilaginous  cells  and 
the  cells  of  the  bone-marrow.     Inasmuch  as  the  portion 


J 


HEREDITARY  OR  CONGENITAL  SYPHILIS      165 

of  the  medullary  space  which  lies  next  to  the  epiphysis  is 
filled  with  granulation  tissue  in  which  osteoblasts  are 
absent,  there  is  no  deposit  of  osteoid  tissue  on  the  calcified 
bony  trabeculae.  Temporary  calcified  cartilage  and  med- 
ullary spaces,  filled  with  degenerated  granulation  tissue, 
are  therefore  arranged  atypically  side  by  side.  In  place 
of  permanent  bone  there  is  a  development  of  extensively 
calcified  cartilage  ;  this  is  more  easily  fractured,  esjx'cially 
in  the  sheath,  where  it  is  interrupted  by  medullary 
spaces. 

Here  also  occurs  the  epiphyseal  separation.  Healing 
depends  upon  the  fact  that  the  medullary  spaces  are  cap- 
able of  forming  osteoblasts ;  as  a  result,  permanent  bone 
is  built  up  and  the  calcified  cartilage  disappears. 

Osteochondritis  and  Rachitis. — In  both  conditions  an 
interference  with  bony  development  is  the  cause,  only  in 
rachitis  there  is  a  defect  in  the  development  of  inorganic 
— and  in  syphilis  of  organic — constituents  of  bone.  That 
is,  in  rachitis  there  is  an  insufficient  deposition  of  calcium 
salts  with  the  undisturbed  formation  of  osteoid  tissue, 
while  in  syphilis  there  is  no  interference  with  the  excre- 
tion of  lime,  but  an  insufficient  development  of  young 
bone  tissue. 

Diagnosis. — In  children  born  dead,  without  pronounced 
symptoms  of  syphilis,  the  detection  of  osteochondritis 
and  increased  body  weight  is  of  significance.  Microscopic 
examination  of  the  kidney  for  the  presence  of  perivascu- 
lar infiltration  is  recommended  because  maceration  of 
that  organ  is  late  in  development ;  likewise  examine  the 
thymus.  Infiltration  must  be  diffi[^rentiated  from  the  phys- 
iologically rich  sup]>ly  of  cells  in  youthful  tissue,  espe- 
cially in  the  liver,  kidneys,  and  lungs.  Care  must  be  ob- 
served in  the  preservation  of  macerated  preparations, 
which  are  stained  with  difficulty. 

In  living  children  note  the  chief  symptoms :  Snuffles, 
pemphigus,  enlargement   of  liver  and   spleen,  and   in- 
sufficient   body    weight   as    early    manifestations  ;    late\ 
maculopapular  exanthems,  diffuse  infiltration  of  the  skin, 
and  rhagades  of  the  nose,  mouth,  and  anus.     Of  signifi- 


166  CHRONIC  INFECTIOUS  DISEASES 

PLATE  14 

Fio.  1.  Congenital  Syphilis  of  the  Intestines.— Cross-section  of  the 
small  intestiiui  of  a  seven-months' -old  syiibilitic  child  which  was  dead 
when  born.  Magnified  60  times.  A  circumscribed  specific  infiltration, 
which  may  even  be  detected  macroscopically,  lies  between  the  mucosa 
and  submucosa ;  it  has  resulted  in  loosening  of  the  former.  1.  Thick- 
ened peritoneum.  2.  Muscular  coat.  3.  Submucosa.  4.  Sj'philitic  iufil- 
tnition.  5.  Loosened  mucosa.  (5.  Normal  mucosa.  7.  Intestinal  con- 
tents. 

Fig.  2.  Syphilitic  Osteochondritis.— Longitudinal  section  of  the 
distal  epiphysis  of  the  femur  of  a  case  of  congenital  syphilis  in  a  seven- 
months' -old  infant  born  dead.  Magnified  6  times.  The  border  between 
the  bone  and  cartilage  is  serrated.  The  zone  of  temporary  calcification 
of  the  cartilaginous  ground  substance  is  wider  than  nornial,  and  extends 
into  the  diaphysis  as  well  as  into  the  cartilage.     1.  Resting  cartilage. 

2.  Cartilage  cells  arranged  in  columns  which  have  been  compressed  be- 
tween the  calcified  cartilage  tissue  and  crowded  proliferating  cartilage. 

3.  Large  vesicular  cartilage  cells,  in   process  of  beginning  ossification. 

4.  Calcified  cartilage  ground  substance.  5.  Primary  medullary  si>ace, 
filled  w^ith  granulation  tissue.  6.  Calcified  cartilage  surrounded  bj'  gran- 
ulation tissue. 

cance  in  doubtful  cases,  as  during  the  intervals  between 
recurrences,  are  numerous  deaths  in  the  family,  lack  of 
body  weight,  radiating  scars  on  the  lips,  splenic  tumor, 
yellowish,  dirty  skin,  and  swollen  cubital  lymj)h-nodes. 

Following  are  the  conditions  for  which  .syphilis  might 
be  mistaken :  Pemphigus  imlgaris.  Development  after 
the  first  week  of  large  soft  vesicles,  which  do  not  involve 
the  palms  nor  the  soles.  Snuffles  are  absent.  The  p/iys- 
iologic  desquamation  and  paronychia  on  the  fingers  and 
toes  appear  in  from  two  to  three  weeks,  and  tlie  other 
symptoms  are  absent.  Simple  coryza,  a  thin  abundant 
secretion.  Congenital  hypertrophy  of  the  nasal  mucous 
membrane,  adenoid  vegetations.  Other  syphilitic  symp- 
toms are  not  present.  The  glossy  reddening  of  the  soles  of 
atrophic  children,  the  denseness  and  desquamation  of  dif- 
fuse specific  plantar  infiltration.  Papular  eczema  of  the 
amiSf  the  palms  and  the  plantar  surfaces  of  the  feet 
remain  free ;  also  found  in  the  neighborhood  of  true 
eczematous  parts  ;  the  other  specific  symptoms  are  absent. 
Spina  veniosa  (in  comparison  with  specific  phalangitis), 
children  older  in  age,  rarely  multiple  on  one  hand,  fail  to 
localize  on  the  first  phalanges,  skin  also  involved,  tend- 
ency to  external  rupture,  of  spheric  and  cylindric  sha|K'. 


G-^r-      i 


Jig.l. 


'-k 


J.4 


6-L 


fcViH^'i'ij 


Fig.  2. 


<i.       r 


HEREDITARY  OR  CONGENITAL  SYPHILIS       167 

Prognosis. — The  severe  cases  die  m  tUero,  and  only  the 
niihl  forms  are  born.  The  prognosis  is  more  favorable 
the  later  the  symptoms  developafter  birth,  and  the  slower 
they  follow  each  other.  The  outlook  is  bad  in  the  pres- 
ence of  pemphigus  and  visceral  syphilis  which  originated 
during  fetul  life.  Relapses  occur  in  about  30  j)er  cent,  of 
all  cases,  and  almost  exclusively  within  the  first  years  of 
life.  A  weakening  of  the  general  system  cannot  be  j)re- 
vented  even  in  the  most  fiivorable  forms.  Death  is  due 
to  marasmus,  septic,  enteritic,  nephritic,  or  pneumonic 
processes.  Syphilis  tarda  usually  terminates  favorably. 
Breast-fed  children  have  better  prospects  than  bottle-fed 
children,  yet  careful  artificial  feeding  may  also  offer  good 
results. 

Treatment:  Prophylaxis. — Marriage  is  not  permissible 
until  at  least  four  years  have  elapsed  since  the  infection 
and  two  years  after  the  last  relapse,  during  which  time  a 
thorough  course  of  treatment  must  have  been  instituted. 
When  syphilis  has  been  manifestly  acquired,  the  parent 
should  receive  energetic  treatment.  AVhen  a  mother  has 
been  infected  during  pregnancy,  the  general  treatment 
should  be  combined  with  the  local  use  of  mercury  by 
means  of  vaginal  suppositories. 

Nourishment. — Whenever  possible,  feeding  should  be 
maintained  by  means  of  the  mother's  milk,  at  least 
throughout  the  acute  stage.  According  to  Colles'  law  the 
mother  is  not  endangered  herself.  No  wet-nurse  should 
be  employed  even  in  a  doubtful  case.  If  necessary,  milk 
obtiiined  artificially  from  the  wet-nurse  may  be  used.  If 
human  milk  is  not  obtainable,  then  resort  to  careful  indi- 
vidual artificial  feeding,  including  artificial  preparations. 

Specifie  Treatment  icith  Mercurt/ and  lodin:  InternaUy. 
— Protoiodid  of  mercury,  0.005  to  0.01  gm.  twice  daily ; 
or  in  combination  with  saccharatcd  ferri  cari)onate,  0.1 
gm. ;  calomel  in  like  doses,  or  with  opium,  0.003  gm. 

ExtcrnaUy. — Sublimate  baths,  1.0  to  1.5  gm.  to  a  bath. 
Caution  should  be  used  in  case  of  excoriated  skin.  Wel- 
ander's  sacks  (6  to  10  gm.  of  mercury  and  chalk  mixture 
smeared  on  the  woolen  side  of  a  piece  of  lint  20  X  40 


1 68  TUBERCUL  OSIS 

PLATE  15 

Congenital  Tuberculosis.— lu  the  atelectatic  lungs  of  a  child  which 
died  a  lew  lioui-s  alter  birth  was  found  a  single  cherry-sized  caseous 
focus  surrouuded  by  a  connective-tissue  capsule  ;  tubercle  bacilli  were 
found  in  this  focus.  The  connective  tissue  in  the  neighborhood  of  the 
focus  was  distinctly  increased.  Other  tuberculous  processes  couhl  not  be 
found.  Such  a  focus  might  have  remained  latent  throughout  life,  or  it 
might  have  been  disseminated  through  an  infectious  disease,  traumatism, 
etc.,  and  a  general  tuberculosis  caused,  (Preparation  in  the  Munich 
Pathologic  Institute.) 

cm.  [8  X  16  in.],  which  is  folded,  sewed  together,  and 
tied  in  place),  wliich  are  to  be  renewed,  as  in  the  case  of 
the  commercial  "  mercolint  aprons,"  after  from  four  to 
six  days.  Wrap  all  four  extremities  at  intervals  of  six 
days  with  mercury  plasters. 

Locally. — A])ply  calomel  to  condylomata;  3  per  cent, 
silver  nitrate  or  10  per  cent,  chromic  acid  solution  to 
rhagades;  red  precipitate  or  1  per  cent,  silver  solution 
to  nose.  Duration  of  treatment  is  about  six  weeks,  in 
any  case  for  fourteen  days  after  the  di.sappearance  of  the 
last  symptom.  In  case  of  gumma  or  retarded  syphilis 
give  sodium  iodid,  1.0  to  2.0  gm.  per  day,  until  the  dis- 
ease is  influenced.  To  combat  cachexia  give  arsenic, 
levico,  etc. 

TUBERCULOSIS 

Frequency. — Next  to  disease  of  the  digestive  tract, 
tuberculosis  is  the  most  frequent  cause  of  death  in 
children  (13  to  20  per  cent.) ;  nearly  30  per  cent,  of  all 
children  possess  latent  tuberculosis.  Of  all  deaths  due 
to  tuberculosis,  30  per  cent,  are  in  children. 

Transmission. — Tuberculosis  is  either  congenital  or 
acquired. 

Congenital  tuberculosis  is  met  with  but  rarely,  and  is 
tmnsraitted  usually  from  a  mother  who  is  suffering  from 
a  severe  form  of  tuberculosis  by  way  of  the  placenta, 
which  is  also,  as  a  rule,  diseased.'     Transmission  of  the 

'  The  bacilli  enter  the  fetal  blood-vessels  or  the  amniotic  sac,  where 
the  fetus  may  swallow  them  with  the  liquor  amnii  (Schmorl) — congen- 
ital gastro-intestinal  tuberculosis. 


lab.  13, 


TRANSMISSION  OF  TUBERCULOSIS  169 

tubercle  bacillus  by  means  of  the  human  ovum  or  the 
spermatozoon  has  never  been  determined  ;  the  first  is 
possible  when  tuberculous  peritonitis  exists,  the  latter, 
iiowever,  highly  improbable  (Gartner).*  Congenital  tuber- 
culosis represents  either  a  general  infection  of  the  fetal 
body  shortly  after  birth  (tuberculous  bacillemia),  or  it 
assumes  the  form  of  tuberculous  foci  disseminated  in  the 
organs. 

Acquired  tuberculosis  is  the  usual  form,  even  in  very 
young  children.  Caseous  foci  are  rarely  seen  before  the 
third  or  fourth  month,  yet  this  period  of  life  favors  the 
development  of  such  foci.  The  infection  is  transmitted 
products  containing  tubercle  bacilli,  either  from  the  parents' 
or  the  child's  surroundings.  The  infection  enters  the 
body  as  follows : 

By  inhalation  of  dried  tuberculous  sputum  or  of  fine 
drops  of  sputum  which  have  been  coughed  into  the  air ; 
the  latter  occurs  only  when  a  person  is  constantly  near 
the  patient.  The  j>rimary  affection  lies  in  the  lungs  them- 
selves, especially  if  a  bronchitis  or  bronchopneumonia  al- 
ready exists,  or  in  the  })eribronchial  and  mediastinal  glands, 
in  which  case  the  bacilli  travel  through  the  lungs  with- 
out injuring  them.  Occasionally  the  first  deposition  of 
the  bacilli  occurs  in  the  pharyngeal  or  palatine  tonsils. 
Inhalation  represents  the  commonest  mode  of  entrance 
for  tuberculosis. 

By  i\\Q  introduction  of  material  containim/  tubercle  bacilli 
into  the  gastro-intestinal  tract,  by  placing  utensils,  toys, 
and  dirty  fingers  (tubercle  bacilli  have  been  demonstrated 
in  the  dirt  of  the  finger-nails)  in  the  mouth,  and  by  the 
ingestion  of  raw  milk  or  meat  from  tuberculous  cows. 
Here  also  the  bacilli  may  pass  through  the  intestinal 
walls,  and  collect  in  the  regional  lymph-nodes  of  the 
nu'sentery  and  j)eritoneum.  It  is  difficult  to  determine 
whctiuM-  the  disease  is  due  purely  to  the  ingestion  of  in- 
fected food — for  tuberculosis  of  the  intestines  and  mesen- 

^  The  number  of  tubeix-le  bacilli  in  the  spermatic  fluid  is  very  in- 
significant in  compariww  with  the  enormous  niuuber  of  spermatozoa, 
and  no  spermatozoa  have  ever  been  found  to  contain  tubercle  bacilli. 


170  Tuberculosis 

teric  nodes  may  be  secondary  to  infection  through  the 
lymph-channels  from  bronchial  nodes — or  to  the  swallow- 
ing of  tuberculous  sputum. 

From  the  mucous  membrane  of  the  mouth,  pharynx, 
nose,  and  genitals,  as  well  as  the  external  skin,  when  these 
tissues  are  damaged  or  even  when  they  remain  uninjured, 
provided  they  come  in  intimate  contact  with  the  bacteria 
(Cornet).  The  lips,  tonsils,  and  carious  teeth  are  espe- 
cially prone  to  admit  the  infection. 

PECULIARITIES  OF  TUBERCULOSIS   IN  CHILDREN 

Tuberculosis  of  childhood  is  nearly  always  a  general 
disease  which  involves  numerous  organs  and  occurs  rarely 
before  the  third  month,  reaching  its  maximum  in  from  two 
to  four  years.  Characteristic  of  infantile  tuberculosis  is 
the  early  and  constant  involvement  of  tlie  lymph-notles, 
especially  the  peribronchial,  and  also  the  cervical,  abdom- 
inal, and  inguinal  nodes.  Disease  of  the  lymph-nodes 
is  frequently  the  only  manifestation  of  tuberculosis — 
latent  tuberculosis.  In  nurslings  the  lesions  usually  met 
with  are  tuberculous  disease  of  the  bronchial  nmles,  with 
caseous  pneumonia  of  the  neighboring  pulmonary  tissue 
or  a  generalized  tuberculosis.  The  follow'ing  varied  mani- 
festatians  of  tuberculosis  do  not  occur  until  later  in  child- 
hood :  Affections  of  the  bone-marrow,  serous  membranes, 
meninges,  jieritoneum,  pleura,  tendon-sheaths,  and  joints. 
As  children  grow  older  the  symptoms  assume  the  character 
of  adult  tuberculosis. 

Predisposition. — This  is  either  congenital,  on  account  of 
a  weak  constitution,  consisting  of  certain  anatomic  pecu- 
liarities of  the  skin,  mucous  membranes,  and  lymphatics, 
which  are  inherited  from  parents  suffering  from  some 
dyscrasia,  or  it  is  acquired  through  unhealthy  conditions 
of  life,  jx>or  nourishment,  or  wasting  diseases.  Latent 
tuberculosis  is  frequently  made  active  and  manifest  by 
febrile  diseases,  especially  measles,  whooping-cough,  in- 
fluenza, and  inflammation  of  the  lungs. 

Paths  of  Dissemination. — The  inhaled  tubercle  bacillus 
is  deposited  on  the  pharyngeal  or  palatine  tonsils,  which 


PECVLIARITIES  OF  TUBERCULOSIS  IN  CHILDREN    171 

arc  primarily  infected,  or  penetrated  to  reach  the  regional 
lyinph-nodos ;  or  it  travels  to  the  finer  bronchial  tubes, 
where  it  begins  the  primary  affection  with  a  caseating 
bronchitis,  peribronchitis,  and  bronchopneumonia  ;  or  even 
more  frequently  it  pierces  the  bronchial  walls  and  reaches 
the  lymph-nodes  by  way  of  the  lymph-channels.  Here 
it  causes  the  formation  of  minute  tubercles,  which, 
becoming  confluent,  form  larger  ones;  these  become 
swollen  and  undergo  chronic  inflammation,  and  finally, 
necrosis  with  caseation,  softening,  and  calcification.  Here 
under  certain  circumstances  the  process  comes  to  a  stand- 
still— latent  tuberculosis.  Tuberculosis  may  extend  from 
the  bronchial  nodes  in  the  following  ways  : 

By  contiguity  to  the  neighboring  lung  tissue — peri- 
glandular caseous  pneumonia. 

By  way  of  the  lymph-channeh  to  various  parts  of  the 
lungs — lymphogenic  tuberculous  peribronchitis — or  also 
to  distant  structures  (abdominal  lymph-nodes,  bones, 
and  joints). 

Rupture  of  a  calcified  and  softened  nodular  focus  into 
a  bronchus.  Dissemination  of  tuberculous  material  by 
aspiration — tuberculous  caseous  bronchopneumonia. 

Rupture  of  such  a  focus  into  the  esophagus — infection 
of  the  gasiro-intestinal  tract  (this  may  also  follow  swallow- 
ing of  infected  sputum). 

Rupture  into  the  circulation,  either  by  way  of  a  pulmo- 
nary artery  or  a  vessel  leading  to  the  heart  (vein,  artery, 
thoracic  duct).  In  the  first  case  disseminated  pulmonary 
tuberculosis  results,  and — according  to  the  position  of  the 
vessel — the  whole  lung  or  only  part  of  it  is  involved  ;  in 
the  latter  case  (rupture  into  a  vein,  etc.)  dissemination 
throughout  the  whole  body  leads  to  generalized  tubercu- 
losis. A  particular  manifestation  of  this  form  is  acute 
miliary  tuberculosis,  which  develops  when  a  large 
amount  of  the  infective  material  is  discharged  into  the 
circulatiou  at  one  time,  or  when  vital  organs  like  the 
basilar  meninges  are  attacked  by  tuberculous  meningitis. 
In  both  cases  the  resulting  miliary  foci  liave  not  sufficient 
time  to  develop  into  larger  disseminated  nodules. 


172  TUBERCULOSIS 

Certain  ]>henomena  of  tuberculosis  are  possibly  not 
caused  by  live  bacilli,  but  by  the  dead  bacilli  or  their 
soluble  products.  Thus  experimental  investigation  has 
shown  that  general  marasmus,  cold  abscesses,  and  casea- 
tion are  due  to  dead  tubercle  bacilli  or  their  extracts. 


SYMPTOMS  OF  GENERAL  TUBERCULOSIS 

Subacute  and  chronic  general  tuberculosis  are  manifested 
anatomically  by  foci  in  process  of  caseation,  varyiug  in 
size  from  a  hemp-seed  or  lentil  to  a  hazel-nut,  which  are 
spread  throughout  the  lungs,  spleen,  kidneys,  and  brain 
(solitary  tubercles),  accompanied  by  primary  older  foci  in 
the  bronchial  or  mesenteric  nodes.  The  clinical  signs 
are  loss  of  appetite,  apathy,  cough,  sweats,  and  gastro- 
intestinal disturbances.  The  objective  symptoms,  if  any 
are  present,  consist  of  dark  circles  surrounding  the  eyes, 
a  slight  or  hectic  fever  which,  in  spite  of  its  persistence, 
is  unaccompanied  by  febrile  disturbances ;  swelling  of  the 
small  subcutaneous  lymph-nodes  (micropolyadenoi^thy) ; 
chronic  bronchitis;  indications  of  the  involvement  of  the 
bronchial  lymph-nodes ;  pneumonic  infiltration  ;  enlarge- 
ment of  liver  and  spleen  ;  nodules  in  the  skin,  varying 
in  size,  or  dirty  grayish-brown  elevated  specks  which  are 
dry  and  subdivided  ;  and,  more  important  than  all,  a 
progressive  emaciation. 

Other  significant  manifestations  are  :  A  caries  encir- 
cling the  teeth  (Neumann);  small  semisoft  nodules  on  the 
face  which  resemble  incompletely  developed  furuncles, 
without  a  tendency  either  to  suppuration  or  to  resolution 
(Heubner) ;  considerable  growth  of  hair  between  the 
scapulffi  (Heubner). 

Acute  general  tuberculosis  (miliary  tuberculosis)  is  charac- 
terized anatomically  by  minute  gray  nodules  in  nearly  all 
of  the  organs  of  the  chest  and  abdomen,  the  meninges, 
etc.  It  is  accompanied  by  marked  constitutional  disturb- 
ances, a  high  fever,  diarrhea,  meteorism,  splenic  tumor, 
slight  cyanosis,  dyspnea,  and  fremitus  over  both  lungs 
without  pronounced  pneumonic  symptoms.     If  the  brain 


TUBERCULOSIS  OF  THE  BRONCHIAL  NODES     173 

cov^erings  are  also  involved,  meningitis  predominates  the 
tliscase  picture  from  beginning  to  end. 

Diagnosis. — Only  an  approximate  diagnosis  can  be 
made  in  case  of  latent  glandular  tuberculosis  and  chronic 
general  tuberculosis.  The  detection  of  the  tubercle 
bacilli  in  young  children  is  difficult,  even  in  the  mucus 
which  is  removed  from  the  mouth,  for  the  absence  of 
ulcerative  j)rocesses  hinders  the  appearance  of  the  bacilli 
in  the  expectoration.  The  tuberculin-tost  presents  a 
harmless  and  sure  method  for  diagnosis  (Schlossmann). 
[This  last  statement  is  not  generally  accepted.  There 
are  a  sufficient  number  of  cases  on  record  where  an  active 
tuberculosis  has  been  lighted  up  from  a  latent  one  by  the 
injection  of  tuberculin.  Enough  so  to  make  clinicians 
cautious  in  the  use  of  this  test. — Ed.] 

TUBERCULOSIS  OF  THE  BRONCHIAL  NODES 

When  tuberculosis  of  the  bronchial  nodes  is  well 
developed,  a  symptom-complex  results,  which  is  more 
likely  to  be  characterized  by  the  appearances  of  a  consti- 
tutional disease  than  by  pathognomonic  local  symptoms. 

Morbid  Anatomy. — Enlargement  of  the  normal  nodes 
lying  at  the  bifurcation  of  the  bronchi  and  behind  the 
sternum,  to  a  size  varying  between  that  of  a  bean  and  a 
walnut ;  the  nodes  are  joined  into  clumps.  In  the  dif- 
ferent nodes  the  following  individual  stages  of  the  tuber- 
culous process  may  be  recognized  side  by  side :  Building 
of  tubercles,  infiltration,  caseation,  softening,  calcification, 
and  connective-tissue  induration. 

Symptoms. — A  peevish  or  apathetic  disposition;  pallor; 
arrested  or  gradual  loss  of  body  weight,  w'ithout  any  real 
disturbance  of  the  appetite  and  the  intestinal  functions ; 
inconstant  fever;  slight  dyspnea  (without  any  evident 
pulmonary  lesion).  Enlargement  and  induration  of  the 
cervical  nodes,  and  especially  the  su])raclavicular  ones, 
which  join  under  the  clavicles  and  form  a  garland  of 
nodes,  from  which  extension  into  the  thoracic  cavity 
may  naturally  be  expected.  Small  areas  of  dulness  are 
found  at  one  side  of  the  sternum,  and  at  the  sternal  end 


174 


TUBERCULOSIS 


of  the  first  and  second  intercostal  spaces,  and  in  severe 
cases  also  posteriorly  between  the  scapula; ;  the  respira- 
tory murmur  is  exaggerated  in  these  areas. 


Fio.  63. — Chronic  swelling  (tuberculous)  of  the  thoracic  and  abdominal 
lymph-nodes.  A  frontal  frozen  section  of  a  boy  four  and  a  half  years 
old,  showing  the  close  relationship  of  the  glands  to  the  large  blood-ves- 
sels, also  the  position  and  size  of  the  thoracic  and  abdominal  viscera. 
1.  Trachea.  2.  Lymph-nodes.  3.  Aorta.  4.  Pulmonary  artery.  (After 
J.   Symington.) 


SCROFULA  175 

Symptoms  which  are  caused  by  the  pressure  of  the 
clumps  of  nodes  u[)on  nerves,  blood-vessels,  and  air-pas- 
sages :  Paroxysms  of  cough  similar  to  whooping-cough, 
but  without  the  inspiratory  whoop;  hoarseness;  increased 
frequency  of  the  pulse  (paralysis  of  the  recurrent  and 
vagus  nerves);  prominence  of  the  engorged  veins  of  the 
face,  neck,  and  thorax;  clubbing  and  slight  cyanosis  of 
tlu;  terminal  phalanges  of  the  hand  (compression  of  the 
large  venous  trunks)  ;  signs  of  stenosis  with  respiratory 
retraction  and  whistling  respiratory  murmurs  (pressure 
upon  the  trachea  and  bronchi). 

Painfulness  of  several  spinous  processes  between  the 
second  and  seventh  dorsal  vertebrae  (spinalgia)  is  claimed 
to  be  characteristic  (Petruschky). 

Although  these  symptoms  are  not  pathognomonic  in 
themselves,  yet  they  become  suspicious  when  present  in 
children  who  possess  a  predisposition  to  tuberculosis,  or 
in  tiiose  who  have  recently  passed  through  an  attack  of 
measles,  whooping-cough,  or  influenza,  or  in  those  suffer- 
ing from  some  other  form  of  tuberculosis  or  scrofula. 

SCROFULA 

Scrofula  is  a  combination  of  chronic  swelling  of  the 
lymph-nodes  with  certain  inflammatory  affections  of  the 
skin  and  mucous  membranes,  which  are  characterized  by 
their  obstinacy,  tendency  to  relapses,  their  combined 
appearan(^e,  and  their  occurrence  almost  exclusively  in 
childhood. 

TUBERCULOSIS  AND  SCROFULA 

Scrofula  is  closely  related  to  tuberculosis  and  in  certain 
respects  identical.  Corroborating  this  view  are  :  Scrofu- 
lous manifestations  arc  very  often  associated  with  genuine 
tuberculous  affections,  tuberculosis  of  the  bronchial  nodes, 
lupus,  caries  of  the  bones,  exostoses,  and  joint  disease,  in 
all  of  which  either  tuberculosis  or  scrofula  are  ])rimary. 
Simple  glandular  swelling  is  frequently  observed  to  de- 
velop into  true  tuberculosis  of  the  lymph-nodes.  Post- 
mortem   examinations   of    scrofulous    children    always 


176  TVBERCVLOSrs 


PLATE  i6 


Scrofula. — Boy  six  years  old.  Chronic  rhinitis  with  excoriations 
and  thickened  upper  lip;  chronic  right  blepharoconjunctivitis,  chronic 
left  keratitis ;  the  facial  expression  shows  sensitiveness  to  light. 


reveal  tuberculosis  of  the  bronchial  nodes  (Heubner). 
Tiie  majority  of  scrofulous  subjects,  including  tho.se  witli- 
out  evident  glandular  swelling,  react  positively  to  tuber- 
culin (Heubner).  Primarily  the  tubercle  bacillus,  which 
because  of  its  minute  size  can  pass  through  the  skin  and 
mucous  membranes  without  causing  any  damage,  enters 
a  bronchial;  cervical,  or  mesenteric  node,  and  sets  up  a 
true  chronic  tuberculosis.  The  resulting  impairment  of 
the  general  health  lessens  the  resisting  power  of  the  body, 
which,  together  with  the  fact  that  in  certain  chiklren  the 
permeability  of  the  skin  and  mucous  mend)ranes  ("ex- 
ternal barrier ")  to  bacteria  is  already  increased,  offers 
but  little  resistance  to  the  entrance  of  pus-exciting  micro- 
organisms and  tubercle  bacilli.  The  scrofulous  catarrh 
of  the  mucous  membranes,  eczema,  etc.,  in  which  some- 
times pyogenic  cocci  and  at  other  times  tubercle  bacilli 
are  found,  may  therefore  be,  but  not  necessarily,  tubercu- 
lous. Likewise  the  swelling  of  the  lymph-nodes  ("  inner 
barrier"),  depending  upon  the  affection  of  the  region  they 
drain,  may  be  of  a  pyogenic  or  a  tuberculous  character. 
The  presence  of  a  tuberculosis  of  the  internal  glands  must 
be  excluded. 

Symptoms. — General  ManifeMatlons. — At  first  the  gen- 
eral appearance  is  still  fresh,  but  later  it  is  nearly  always 
pale ;  as  a  rule,  there  is  no  emaciation,  rather  a  certain 
increase  of  fat;  the  body  and  mind  are  easily  fatigued  ; 
dull  and  often  irritable  temperament ;  lo.ss  of  appetite ; 
headache ;  shooting  pains  in  the  chest.  Typic  facial 
expression  :  Thickened  nose,  which  is  excoriated  at"  the 
nostrils  by  the  secretion;  thick,  protruding  upi)er  lip; 
reddened,  thickened  eyelids,  which  are  spasmodically 
contracted  on  account  of  photophobia. 

Lymph-nodes. — Swelling  is  at  first  localized  in  the 
superficial  nodes  of  the  neck,  lower  jaw,  and  angle  of  the 


TiU,.n 


SCROFULA  177 

jaw.  By  contiguity  the  process  spreads  to  neighboring 
nodes,  and  at  times  also  by  retrograde  infection  of  bron- 
chial nodes  from  blocking  of  the  lymph-stream.  The 
size  of  the  nodes  varies  between  a  lentil,  a  hazel-nut,  or 
a  walnut.  Perinodular  inflammation  causes  a  number 
of  nodes  to  form  large  clumps.  At  first  the  nodes  are 
movable  underneath  the  skin,  but  later  they  are  adherent. 
Characteristic  of  this  condition  are  painlessness,  gradual 
increase  in  growth,  and  a  tendency  of  the  nodular 
hyperplasia  to  undergo  necrosis;  unless  resorption  oc- 
curs, caseation,  calcification,  or  softening  and  suppuration 
set  in.  If  suppuration  exists,  the  surrounding  connec- 
tive tissue  is  infiltrated,  the  skin  becomes  thinner,  and 
an  abscess  is  formed,  which  ruptures  externally  unless 
incised.  The  abscess  contains  granular  pus,  shows  but 
little  tendency  to  heal  after  evacuation,  and  often  leads, 
after  the  existence  of  fistula  for  a  long  time,  to  the  for- 
mation of  radiating  scars. 

Not  every  case  of  lymphadenitis  is  scrofulous ;  the 
secondary  glandular  involvement  of  eczema,  dental  caries, 
angina,  stomatitis,  etc.,  are  usually  distinguished  without 
difficulty  by  their  acute  course,  while  lymphomatous 
tumors  are  recognized  by  their  persistency. 

Skin. — The  following  are  the  various  scrofulous  affec- 
tions  of  the  skin  : 

Subctdaneous  infiltrations  which  develop  slowly,  unac- 
companied by  manifestations  of  pain  or  inflammation,  in 
various  parts  of  the  body;  these  infiltrations  lead,  in 
the  course  of  time,  to  indolent  ulcers  which  have  serrated 
edges  (scrofuloderma). 

Chronic  impetiginous  eczenui  of  the  face,  scalp,  ear,  and 
surroundings. 

E-thi/ina  pustules  on  the  lower  half  of  the  body,  with 
deep-seated  ulcers. 

Lichen  scrofulosum,  which  is  probably  miliary  tubercu- 
losis of  the  skin. 

Mucous  Membranes.  —  Ei/cs.  —  Blepharoconjunctivitis, 
thickening  of  the  eyelids,  peripheral  phlyctenula,  accom- 
panied by  ]ihotophobia  and  blepharospasm,  tendency  of 


178  TUBERCULOSIS 

the  infiltrated  tissue  to  undergo  ulceration,  keratitis, 
iritis,  and  finally,  more  or  less  permanent  corneal  opacity 
(leukoma). 

Nose. — Obstinate  rhinitis  with  tough,  pus-like  secre- 
tion, which  forms  crusts  and  excoriates  the  nostrils,  lead- 
ing to  nasal  obstruction  and  thickening  of  the  nose  and 
upper  lip ;  in  severe  cases  there  is  a  destructive  atrophic 
ozena. 

Pharymv. — Hypertrophic  pharyngitis,  chronic  inflam- 
mation, and  hyperplasia  of  the  palatine  tonsils,  and  espe- 
cially the  pharyngeal  tonsil,  with  all  the  consequences  of 
those  affections.     (See  Adenoids.) 

Ear. — Fetid,  pus-like,  and  perforative  otitis  media, 
usually  double,  followed  by  extension,  mastoiditis,  etc. 

Other  phenomena  noted  are  caries  encircling  the  neck 
of  the  tooth  and  a  persisting  gastro-intestinal  and  bron- 
chial catarrh. 

Course  and  Prognosis. — The  course  is  always  chronic, 
yet  it  varies  according  to  the  individual's  strength,  the 
degree  of  extension,  and,  above  all,  the  possibilities  as  to 
treatment  and  attention.  In  favorable  cases,  although 
of  long  duration,  complete  cure  may  be  achieved ;  in 
others  the  condition  is  made  worse  by  the  advent  of  bone 
caries,  lupus,  pulmonary  and  general  tuberculosis,  and 
meningitis.  The  prognosis,  therefore,  is  always  some- 
what doubtful,  especially  when  caseous  foci  already  exist. 

Diagnosis. — Although  the  occurrence  of  glandidar 
swelling,  catarrh  of  the  mucous  membrane,  and  eczema 
is  met  with  in  other  conditions  than  scrofula,  yet  they 
point  toward  the  latter  by  their  simultaneous  occurrence, 
their  persistence,  and  tendency  to  recurrence.  Of  diag- 
nostic importance  is  the  general  habitus  and  the  facial 
expression.  Positive  tuberculin  reaction  would  support 
the  diagnosis. 

THE  TREATMENT  OF  TUBERCULOSIS  AND  SCROFULA 

Prophylaxis. — Institute  careful  nursing  and  feeding; 
instruct  parents  as  to  the  hygienic  care  of  their  children; 


TREA  TMENT  OF  TUBERCULOSIS  AND  SCROFULA     1 79 

careful  hardening  of  the  body  against  changes  in  tempera- 
ture and  disease ;  encourage  a  certain  amount  of  physical 
laziness ;  use  ])urc  milk.  Discourage  marriage  between 
tuberculous  individuals  ;  proper  ventilation  of  dwellings  ; 
much  time  to  be  spent  in  the  open  air. 

Preventing  Infection  of  Susceptible  Children. — Forbid 
all  association  with  tuberculous  subjects ;  separate  from 
tuberculous  parents,  and  raise  in  children's  sanitaria ; 
w^hen  this  is  not  possible  the  closest  attention  must  be 
paid  to  prevent  infection.  Children  should  be  taught 
cleanliness — frequent  washing  of  the  hands,  care  of  the 
mouth  and  nose,  and  disinfection  of  utensils  and  toys. 
Guard  against  diseases  which  predispose  to  tuberculosis, 
such  as  measles,  whooping-cough,  etc. 

General  Hygienic  and  Dietetic  Treatment. — Light,  well- 
ventilated  dwellings  ;  sojourn  in  mountainous  regions  or  at 
the  sea  ;  careful  supervision  of  air-  and  sun-baths  ;  keep 
the  skin  in  good  condition  and  give  alcohol  rubs  ;  salt-  or 
peat-baths  (see  Rachitis),  also  sand-baths.  Institutional 
treatment  in  children's  sanitaria  and  sea  hospitals ; 
abundant  fatty  foods  :  milk,  cream,  whipped  cream,  kefir, 
butter,  and  infants'  meals;  together  with  chopped  meat 
and  pressed  meat  juice.  As  a  rule  give  a  mixed  diet,  but 
constantly  alternate  with  green  vegetables,  salad,  fruit, 
and  compote. 

Special  Treatment. — Soft-soap  Care. — Dilute  the  tinct- 
ure of  green  soap  with  a  little  warm  water  and  rub  it 
daily  into  the  skin  of  the  trunk  and  the  extremities,  and 
wash  it  off  in  ion  minutes.  To  combat  the  glandular 
swelling  make  hydropathic  applications  with  gruel,  mud, 
or  decoctions  of  oak  bark.  Also  smear  the  body  with 
potassium  iodid  ointment  or  iodovasogen,  alsoin  combina- 
tion with  equal  parts  of  soft  soap,  covered  with  cotton  and 
allowed  to  remain  over  night.  Large  masses  of  lymph- 
nodes  are  extirj)ated  before  softening  sets  in.  Adenoid 
vegetations  and  hyperplastic  tonsils  should  be  removed. 

Medication. — One  child's  spoonful,  twice  daily,  of 
brown  or  light  cod-liver  oil  alone  or  combined  with  1  to 
3  per  cent,  creosote  carbonate  (creosotal).     Cod-liver  oil 


180  TUBERCULOSIS 

PLATE  17 

Acute  Disseminated  Tuberculosis  of  the  Lungs.— BronchoKcnic 
form — bronchiolitis  nodosa.  The  bronchial  luiuiua  may  be  recognized  iis 
points  within  the  miliary  foci.  Chronic  caseous  tuberculosis  and  partial 
softening  of  the  tracheal  and  bronchial  lymph-nodes.  Two-year-old 
child.  Duration  of  disease,  four  weeks.  Clinical  history  :  Bemittiug 
fever,  dyspnea,  cyanosis,  no  evident  dulness,  and  emaciation. 

may  be  substituted  for  lipanin  or  Mehring's  chocolate. 
Tasteless  guaiacol  carbonate  ("  duotal"),  0.1  to  0.3  gm. 
])or  dose.  Guaiacol  valerianate  ("  geosot "),  4  to  8  dro|)s 
throe  times  a  day;  thiocol,  sufficient  to  cover  a  knit'o- 
])()int,  three  times  a  day.  Sirolin  or  sulfusot  syrup,  1 
cofteespoonful  three  times  a  day.  Syrup  of  the  io<lid  of 
iron  with  simple  syrup,  of  each  8  to  20  drops  ;  or  the 
iodid  of  iron  with  malt  extract,  iodoferratose.  To  stim- 
ulate the  appetite  give  the  compound  tincture  of  cinchona 
in  1-drop  doses,  or  wine  of  iron  and  quinin  in  coffeespoon- 
fid  doses  after  meals. 

To  Combat  the  Phlyctenular  Keratoconjunctivitis. — Yel- 
low mercuric  oxid  ointment,  1  to  3  ])er  cent. ;  for  obsti- 
nate infiltrations,  dust  with  calomel;  for  the  photophobia, 
hold  the  head  in  cold  water.  Treat  the  nasal  infection 
with  douches  of  warm  salt-water  and  apply  white  precip- 
itate salve.  (For  treatment  of  the  Eczema,  see  the  section 
on  that  subject.)  The  therapy  of  acute  generalized  tuber- 
culosis consists  in  supporting  the  patient's  strength,  com- 
bating the  fever  with  hydrotherapeutic  measures  of  medi- 
cation, and  relieving  the  pain  with  narcotics. 


TUBERCULOSIS  OF  THE  LUNGS 

Excepting  the  bronchial  gland.s,  the  lungs  represent  the 
])art  of  the  infantile  body  most  frequently  affected  by 
tuberculosis. 

Morbid  Anatomy. — The  following  are  the  forms  of  pul- 
monary tuberculosis  which  occur  in  children.  They  may 
occur  singly  or  in  combination  : 

Acute  Disseminated  Tuherculods  {Miliary  Tuberculosis). 
— This  type   may  be  either  hematogenous  or  bronchial 


Tab.  17. 


TUBERCULOSIS  OF  THE  LUNGS  181 

in  origin,  according  to  whether  the  caseous  focus  ruptures 
into  a  blood-vessel  or  a  bronchus.  When  only  isolated 
portions  of  the  lungs  are  involved  the  course  is  slower 
and  larger  nodules  are  formed — subacute  and  chronic  dis- 
seminated tuberculosis. 

The  hematogenous  miliary  tuberculosis  consists  of 
minute  nodules  scattered  throughout  the  lungs  and  pleura, 
not  involving  the  smallest  bronchi ;  hyperemia  and  con- 
solidation of  the  lung  tissue.  It  is  usually  a  part  of  gen- 
eral miliary  tuberculosis.  In  the  bronchogenic  form  the 
nodules  lie  in  the  walls  of  the  smallest  bronchi — bron- 
chiolitis nodosa — which  finally  spread  to  the  neighboring 
pulmonary  tissue. 

Caseous  peribronchitis  is  due  to  extension  from  old  foci 
along  the  lymph-vessels  of  the  bronchi,  and  is  accom- 
panied by  caseous  thickening  of  the  bronchial  wall  and 
consolidation  in  the  neighborhood. 

Chseous  pneumonia  is  either  perinodular,  by  direct 
extension  of  the  tuberculous  process  (frequent  in  nurs- 
lings), or  by  confluence  and  spreading  of  peribronchial 
foci.  The  affected  area  is  tense,  on  cross-section  has 
a  yellowish-red  to  yellowish-white  color,  and  appears 
granulated  because  of  the  exudate  from  the  alveoli. 

Secondary  tubercxdosis  develops  from  pre-existing  infil- 
trations which  follow  catarrhal  or  ci'oupous  pneumonia. 

These  various  forms  may  develop  into  chronic  phthisis, 
with  the  formation  of  cavities,  connective  tissue,  indura- 
tion, calcification,  etc.  This,  the  true  "consumption  of 
the  lungs,"  attacks  the  bases  of  the  lungs,  as  a  rule,  and 
is  rarer  in  children  than  in  adults. 

Symptoms. — These  vary  according  to  the  nature  of  the 
process.  The  manifestations  of  general  tuberculosis 
are  always  demonstrable,  and  very  frequently  before 
the  appearance  of  the  disease  itself,  in  the  form  of 
primary  glandular  tuberculosis.  Acute  miliary  tubercu- 
losis, frequently  the  termination  of  other  tuberculous 
affections,  usually  begins  acutely  with  a  high  temperature, 
which  later  runs  the  course  of  a  constant  or  cachectic 
fever,  with  increased  respiration  (40  to  60)  of  a  sighing 


182  TUBERCULOSIS 

character,  increased  pulse-rate,  cyanosis,  anemia,  and 
increasing  emaciation  throughout  the  course  of  the  dis- 
ease. There  is  an  irritable  cough,  usually  without  expec- 
toration (because  the  tubercles  are  mostly  extrabronchial); 
in  general  the  system  may  be  looked  upon  as  being  in  the 
typhoidal  state.  Objectively  the  lungs  present  no  change 
or  only  a  dry  catarrhal  capillary  bronchitis;  the  spleen 
and  liver  are  swollen  at  times,  and  frequently  older  tuber- 
culous foci  are  found  in  the  lungs  and  other  organs. 
Death  follows  the  development  of  diarrhea,  convulsions, 
and  weakening  of  the  heart.  The  subacute  and  chronic 
forms  of  disseminated  bronchial,  hematogenic,  and 
lymphogenic  tuberculosis  present  a  more  gradual  onset,  a 
hectic  fever,  anemia,  and  emaciation  ;  mild  dyspnea,  vari- 
able areas  of  dulness,  which  are  localized  with  difficulty ; 
the  respiratory  murmur  is  increased  from  vesicular  to  bron- 
chial ;  whistling  and  small  vesicular  nlles  are  heard  ;  yet 
clinically  the  picture  of  bronchopneumonia  is  not  present. 

Caseous  Pneumonia. — A  persistent  lobar  or  lobular  pneu- 
monia, especially  after  measles,  whooping-cough,  or  influ- 
enza, accompanied  by  emaciation  and  loss  of  appetite ;  a 
recently  elevated  or  hectic  fever ;  or  primarily  the  symp- 
toms of  a  progressive  bronchopneumonia  with  dulness, 
rales,  bronchial  breathing,  to  which  are  added  the  symp- 
toms of  the  general  disease.  The  exj^ctoration  is  pus- 
like and  contains  abundant  tubercle  bacilli  (obtain  by 
removing  with  cotton  swabs).  The  didness,  which  fre- 
quently spreads  from  the  spine  toward  the  apices  or  to 
the  region  of  the  scapula,  often  remains  unaltered  for 
many  months. 

Course  and  Prognosis  of  Pulmonary  Tuberculosis. — The 
acute  and  subacute  disseminated  tuberculosis  always  ends 
unfavorably,  usually  after  a  few  days  or  weeks.  Cure  is 
possible  in  the  mild  cases  of  caseous  pneumonia,  but 
never  in  the  severe  types.  Death  follows  cardiac  weak- 
ness, genenilized  tuberculosis,  or  meningitis.  Chronic 
disseminated  tul>erculosis,  like  true  pulmonary  j)hthisis, 
is  more  hopeful  in  children  than  in  adults,  and  permanent 
cure  is  comparatively  frequent. 


TUBERCULOUS  PLEURISY  183 

Diagnosis. — The  following  are  the  clmracteristics  of  a 
pulnionaiy  disease  which  is  tuberculous  in  nature :  The 
obstinacy  of  the  condition  ;  the  disproportion  between 
the  comparatively  few  local  and  the  severe  general  symp- 
toms J  general  habitus  ;  emaciation  ;  anorexia  ;  cyanosis  ; 
the  existence  of  otiier  tuberculous  affections ;  chronic 
swelling  of  the  lymph-nodes,  especially  the  supraclavicular 
group ;  the  discovery  of  the  tubercle  bacillus ;  jx)sitive 
tuberculin  reaction. 

Treatment. — As  to  prophylaxis,  predisposed  children 
should  be  carefully  watched  after  the  acute  infectious 
diseases,  and  sent,  if  possible,  to  the  country.  In  the 
undoubted  presence  of  pulmonary  tuberculosis  begin  the 
treatment  with  rest  in  bed,  followed  by  the  open-air  cure 
(protected  against  the  wind).  No  sea-baths  ;  on  the  con- 
trary, the  child  should  be  sent  to  a  mountainous  region. 

Medication. — Cod-liver  oil,  creosote,  guaiacol.  Stimu- 
late the  appetite  with  the  compound  tincture  of  cinchona. 
To  allay  expectoration  give  codein  and  the  extract  of  bel- 
ladonna (aa  0.01  to  O.Oo  gm.  a  day).  To  combat  the 
fever  make  cold  applications  and  give  quinin  internally ; 
acetic  acid  for  the  sweats ;  or  1  per  cent,  menthol  or 
spirits  of  the  salicylates.  Gelatin  internally  or  injected 
for  hemoptysis,  or  liquor  ferri  chloridi,  1  to  2  drops. 

TUBERCULOUS  PLEURISY 

This  is  usually  secondary ;  when  it  occurs  as  a  mani- 
festation of  miliary  tuberculosis  the  pleura  usually  con- 
tains minute  tubercles;  when  a  complication  of  pulmo- 
nary tuberculosis,  it  is  usually  of  the  dry  form,  with  the 
formation  of  fibrous  indurations  and  caseating  infiltra- 
tions. If  a  watery  exudate  exists,  the  pleurisy  is  of  the 
serous  or  serosanguineous  type ;  it  is  })urulent  in  form 
when  a  cavity  ruptures  into  the  j>leura,  and  in  that  case 
the  pus  contains  mononuclear  leukocytes. 

Symptoms. — The  onset  is  insidious,  difficult  to  recog- 
nize, and  accomjMinied  by  the  phenomena  of  general 
tuberculosis.     Local   subjective   symptoms    are    absent. 


184  TUBERCULOSIS 

At  first  there  are  slight  pains,  fever,  and  dyspnea.  Later 
there  is  (hdness,  pleural  friction-rub,  diminished  breatii 
sounds  and  fremitus,  lessened  excursion  of  the  diseased 
side,  etc.  This  process  leads  quite  frequently  to  empy- 
ema. (For  treatment,  see  that  of  Tuberculosis  and 
Pleurisy.)  The  diagnosis  is  of  importance  because  pleu- 
risy is  frequently  the  first  manifestation  of  tuberculosis. 

TUBERCULOUS  PERICARDITIS 

This  follows  extension  of  the  pulmonary  process  to 
the  })ericardium.  If  it  involves  both  the  parietal  and 
visceral  pericardium,  they  become  intimately  united.  The 
symptoms  are  similar  to  those  of  ordinary  pericarditis. 
Dry  pericarditis  in  children  is  always  suggestive  of 
tuberculosis. 

The  j)haryngeal  as  well  as  the  palatine  tonsils  may 
become  diseased  primarily  by  aspiration,  that  is,  dirt 
infection,  and  secondarily  through  the  expectorated 
sputum.  In  the  first  form  nodules  are  usually  found 
lying  deep  in  the  glands,  and  in  the  other  tyjje  superfi- 
cial latent  ulcerations  are  found. 

ABDOMINAL  TUBERCULOSIS 

Intestines. — Origin. — It  follows  the  swallowing  of 
tuberculous  material  (also  congenital),  or  generalized 
tuberculosis  by  way  of  the  blood,  and  from  tuberculous 
mesenteric  glands  by  way  of  the  lymph-channels. 

Morbid  Anatomy. — The  solitary  follicles  and  Peyer's 
patches  in  the  lower  small  and  the  large  intestines  are 
infiltrated,  and  breaking  down,  form  ulcers,  the  edges  of 
which  are  irregular,  undermined,  and  infiltrated.  These 
ulcers  s])read  in  a  transverse  direction  in  the  intestinal 
walls  ;  they  are  often  circular  in  outline  and  are  sur- 
rounded by  minute  tubercles.  A  resultant  local  peritoni- 
tis, with  adhesions  of  the  involved  section  of  the  intes- 
tine and  encapsulation  of  the  exudate  frequently  occur. 

Symptoms. — This  condition  develops  either  primarily 
with  a  gradual  onset,  or  it  arises  secondarily  to  already 
existing   tuberculous   disease.     An    intractable  diarrhea 


ABDOMINAL   TUBERCULOSIS  185 

sets  in,  alternating  at  times  with  constipation.  Vague 
abdominal  pain,  with  meteorism,  nausea,  and  loss  of 
appetite.  Aside  from  these  the  following  constitutional 
symptoms  exist :  Emaciation,  sweats,  and  irregular  ele- 
vations of  the  temperature. 

Course  and  Prognosis. — The  course  is  always  pro- 
tracted throughout  months  and  years.  The  outlook  is 
unfavorable  because  of  the  increase  of  the  diarrhea  and 
cachexia. 

Treatment. — Observe  general  hygienic  and  dietetic 
principles.  Preserve  and  increase  the  body  strength; 
hydropathic  applications ;  feed  as  in  case  of  catarrh  of 
the  large  intestine.  Of  the  astringents  give :  Bismuth 
subcarbonate,  subnitrate,  subgallate ;  silver  nitrate  (0.05 
to  100.0  gm.) ;  calumba,  tannigen,  etc.  [In  persistent 
cases  opium  must  be  used  in  sufficient  quantity  to  con- 
trol diarrhea. — Ed.] 

Mesenteric  Nodes. — Tuberculous  disease  of  the  mesen- 
teric nodes  arises  primarily  by  the  entrance  of  the  bacilli 
through  the  intact  intestinal  walls,  or  secondarily  from  an 
already  existing  tuberculosis  of  the  intestines  or  ])eri- 
toneum.  As  in  the  caseof  the  bronchial  nodes,  tubercu- 
losis of  the  mesenteric  nodes  may  arise  as  an  independent 
disease — tabes  mesenterica.  The  swollen  nodes  form 
large  masses,  which  are  packed  closely  together. 

Symptoms. — Those  of  the  general  condition,  together 
with  a  rounded  dome-shaped  abdomen,  the  apex  of  which 
is  at  the  umbilicus ;  dilated  abdominal  veins,  enlarged 
inguinal  glands,  and  abdominal  pain.  If  the  glands  are 
pal])able  (which  is  not  always  the  case),  they  may  be  felt 
as  movable  tumors  deep  in  the  abdomen  near  the  umbil- 
icus. The  diagnosis,  because  of  the  possibility  of  fecal 
masses,  can  only  be  established  after  the  intestines  are 
evacuated.     The  course  is  usually  unfavorable. 

Treatment.  —  Hot  applications,  inunctions  with  soft 
soap;  otherwise  like  that  of  tuberculosis  of  the  bronchial 
glands. 

Peritoneum, — Origin  and  Morbid  Anatomy. — Tubercu- 
lous peritonitis  ari.ses  either  secondarily  to  general  tuber- 


186  TUBERCULOSIS 

PLATE    i8 

Fig.  1.  Chronic  Tuberculous  Peritonitis.  —  Semidome-sbaped  abdo- 
men. Flattened,  chronically  iufiltrated,  and  pigmented  periomphalitis. 
Four-year-old  j;irl.     ((-linic  of  Escherich,  Vienna.) 

Fig.  2.  Umbilical  Fungus. — (See  text,  p.  84.) 

culosis  or  it  is  lymphogenic  in  origin,  following  tubercu- 
lons  ulcerations  of  the  intestines,  abdominal  glands, 
vertebrjfi,  genitalia,  lungs,  etc. 

In  the  first  case  miliary  and  submiliary  nodules  are 
distributed  on  both  visceral  and  parietal  layers,  tiie 
presence  of  which  are  unrecognizable  clinically.  In  the 
second  case — true  tuberculous  peritonitis — there  is  at  first 
the  secretion  of  a  thin  serous  fluid,  this  is  followed  by  a 
serofibrinous,  pus-like,  sanguineous,  or  ichorous  (in  intes- 
tinal perforation)  exudate.  Next,  fibrinous  and  caseous 
deposits  are  formed ;  the  intestinal  coils  adhere  to  each 
other  and  to  the  abdominal  wall,  and  encapsulated 
abscesses  are  formed.  Occasionally  the  peritonitis  is  of 
the  dry  form,  accompanied  by  extreme  thickening  and 
wrinkling  of  the  omentum.  A  fatty  or  cirrhotic  liver  or 
an  amyloid  liver  and  spleen  are  often  met  with. 

Symptoms. — As  a  rule  the  onset  is  gradual,  but  occasion- 
ally it  presents  the  picture  of  an  acute  and,  later,  chronic 
peritonitis. 

Chief  Symptoms. — Gradual  increase  in  the  size  of  the 
abdomen,  which  presently  assumes  an  oval  or  semi  dome 
shajic,  in  marked  contrast  to  the  emaciation  of  the  rest  of 
the  body.  The  abdominal  skin  is  tightly  stretched,  and 
through  it  the  veins  are  visible.  The  umbilicus,  instead 
of  being  flattened,  may  protrude  and  be  infiltrated — peri- 
umbilical inflammation.  Usually  the  presence  of  free 
fluid  is  demonstrable  (light  percussion  and  palpation). 
At  times  a  dense  resistance,  and  the  sha])e  of  exudative 
tumors  arc  palpable.  There  is  but  slight  tenderness  to 
pressure,  but  considerable  intermittent  abdominal  })ain. 
Sometimes  a  respiratory  friction-rub  is  heard  over  the 
spleen  and  liver.  The  stools  are  clay-like,  acid  in  reac- 
tion, and  fatty.  Otherwise  it  presents  the  picture  of  the 
general  disease. 


^ 


TUBERCULOUS  MENINGITIS  187 

Course  and  Prof/nosis. — The  disease  lasts  for  months 
and  years,  with  intervals  of  improvement  or  of  arrest, 
during  which  time  the  exudate  may  be  increased  or 
decreased.  Sometimes  abscesses  may  rupture  at  the 
umbilicus  or  into  the  intestines,  an  event  which  does  not 
favorably  influence  the  course  of  the  disease.  Death 
may  occur  through  a  progressive  marasmus,  acute  j>erito- 
nitis,  general  tuberculosis,  or  meningitis.  In  milder 
cases  spontaneous  healing  gradually  occurs,  with  perma- 
nent encapsulation  ;  the  latter  makes  recurrence  of  the 
condition  possible.  The  prognosis  is,  therefore,  always 
doubtful,  and  is  less  hopeful  in  the  presence  of  caseous 
products  or  other  tuberculous  affections. 

Diagnosis. — Of  significance  is  the  enlargement  of  the 
abdomen  while  the  rest  of  the  body  undergoes  emacia- 
tion ;  symptoms  of  general  involvement,  the  subsequent 
develojmient  of  tuberculous  processes,  and  the  discovery 
of  solid  or  fluid  exudates. 

Treatment. — That  of  the  general  disease.  Rest  in  bed, 
a  non-irritating  but  strength-producing  diet,  milk,  infant 
meals,  eggs,  bouillon,  chopped  meat,  meat  juice,  somatose, 
and  fruit  jellies.  For  the  pain,  make  warm  applications, 
opium.  To  absorb  the  exudates  anoint  with  soft  soap  or 
vasogen.  Internally  give  creosote,  guaiacol.  If  these 
procedures  remain  ineffectual  perform  a  laparotomy,  sim- 
ply remove  the  exudate,  and  institute  drainage.  This 
oj>eration  gives  good  results  in  the  serous,  encapsulated, 
and  dry  form  (mortality-rate  of  operation  27  per  cent.), 
but  is  contra-indicated  in  generalized  tuberculosis  and 
advanced  cachexia. 


TUBERCULOUS  MENINGITIS 

Basilar  Meningitis.  Acute  Hydrocephalus. — Tubercu- 
lous meningitis,  a  local  plionomenon  of  acute  miliary 
tuberculosis,  consists  of  a  tuberculous  inflammation  of 
the  coverings  of  the  brain,  to  which  the  infection  is  trans- 
mitted by  the  circulation.  It  is  frequently  the  terminal 
stasre  of  tuberculosis  (»f  anv  oriran. 


188  TUBERCULOSIS 

PLATE  19 

Acute  Tuberculous  Basilar  Meningitis.— The  blood-vessels  of  the  pia 
are  considerably  congested.  A  deposit  of  a  grayish-yellow  or  greenish 
gelatinous  exudate  in  the  meshes  of  the  pia  between  the  chiasm  and  the 
medulla  oblongata.  Slight  exudates  along  both  Sylvian  fossae,  where  a 
large  number  of  miliary  tubercles  were  found.  The  dilated  ventricles 
of  the  brain  contained  a  slightly  turbid  exudate  (Hydrocephalus  inter- 
nus).  Other  changes  in  the.  body:  Chronic  caseous  tuberculosis  and 
softening  of  the  bronchial  glands.  Beginning  miliary  tuberculosis  in 
the  lungs  and  spleen. 


Morbid  Anatomy. — Hyperemia  of  the  meninges,  es(^- 
cialiy  at  the  base  and  in  the  Sylvian  fossae.  The  arach- 
noid is  stretched,  the  convolutions  flattened  ;  the  periph- 
eral brain  substance  is  often  softened  and  is  torn  when 
the  pia  is  pulled  off.  Deposit  of  a  gelatinou.s,  slightly 
yellow  or  grayish-green  pus-like  exudate  between  the 
meninges  lying  between  the  chiasma  and  medulla  oblon- 
gata. This  exudate  surrounds  the  cranial  nerves  after  their 
exit  and  extends  into  the  Sylvian  fossse.  The  pia,  espe- 
cially along  the  blood-vessels,  contains  miliary  and  sub- 
miliary  tubercles,  in  which  the  bacilli  may  be  detected. 
Tubercles  are  also  found  on  the  convexity,  but  rarely. 
At  times  the  tubercles  cannot  be  observed  macroscopic- 
ally.  Fluid  is  found  in  the  ventricles  and  the  subdural 
spaces — hydrocephalus  intemusaxidi  externus;  dilatation  of 
the  ventricles  and  softening  of  their  walls.  Anemia  of 
the  brain  substance.  Beginning  miliary  tuberculosis  in  the 
lungs,  liver,  spleen,  and  bone-marrow ;  the  latter  is  po.si- 
tively  demon.strable  only  at  times  (Henoch).  Caseating 
foci  in  several  bronchial  or  mesenteric  nodes;  there  is 
also  often  advanced  tuberculosis  of  other  organs. 

Symptoms. — These  are  manifold.  The  disease  is  usually 
divided  for  description  into  the  following  three  .stages  : 
Irritation  of  the  brain,  cerebral  pressure,  and  cerebral 
paralysis.  This  is  not  always  tenable,  for  one  form  tends 
to  merge  into  the  other.  A  division  of  the  various  stages 
from  a  psychic  point  of  view  is  more  suitable,  for  then  the 
groups  of  symptoms  may  be  placed  in  a  more  constantly 
uniform  and  definite  classification.  Accordingly  there  is 
(1)  a  prodromal  stage,  with  depression  of  the  mind  ;  (2) 


Tab.  19. 


/^"d 


f    ^, 


.  > 


/ 


^ 


h 


i 


1^. 


i 


TUBERCULOUS  MENINGITIS  189 

an  initial  stage,  with  apathy  of  the  mind,  but  with  con- 
sciousness remaining  ;  (3)  a  stage  of  somnolence,  and  (4) 
a  stage  of  stupor. 

Following  is  a  picture  of  the  typic  course  of  tuber- 
culous meningitis.  Weeks  and  even  months  before  the 
onset  of  the  disease  certain  prodromal  symptoms  apjiear : 
The  disposition,  which  has  hitherto  been  cheerful,  becomes 
moody,  melancholy,  and  fearful.  The  child  becomes  weak 
and  quiet,  loses  its  appetite,  its  skin  turns  pale,  and  under- 
goes superficial  emaciation.  Its  sleep  is  restless  and  dis- 
turbed by  dreams.  The  patient  yawns  constantly,  has  a 
desire  to  support  its  head  and  to  sleep  during  the  day,  and 
presents  a  dragging,  uncertain  gait.  Occasional  'head- 
aches ;  disturbance  of  the  intestinal  functions  ;  it  tends 
to  be  constipated  and  vomits  from  time  to  time.  These 
symptoms  are  especially  noticeable  in  children  who  have 
been  particularly  healthy,  less  so  in  those  already  subject 
to  tuberculosis. 

The  following  initial  symptoms  occur  at  the  beginning 
of  the  disease :  Continuous  vomiting,  which  is  inde- 
pendent of  the  ingestion  of  food  and  which  continues  in 
spite  of  dietetic  management ;  it  either  ceases  after  a  few 
days  or  continues  until  the  end  ;  headache  chiefly  localized 
in  the  forehead  or  occiput,  which  is  also  described  as  pain 
in  the  neck ;  obstinate  constipation  ;  increased  pulse- 
rate ;  hyperesthesia,  photophobia,  sensitiveness  to  noises 
and  movement.  An  apathetic  and  vacant  expression, 
with  intervals  of  restlessness  and  loud  crying.  In  gen- 
eral, reasoning  is  maintained  ;  the  child  plays  about,  talks, 
and  looks  at  books.  The  sleep  is  restless  and  interrupted 
by  sighing  and  sudden  awakening.  The  tongue  is  coated, 
there  is  anorexia  and  swelling  of  the  spleen.  After  a  few 
days  the  characteristic  symptoms  set  in  :  The  pulse  be- 
comes slower  and  beats  only  100,  90,  80,  or  even  70  times 
a  minute  ;  it  is  irregulai*,  intermittent,  and  of  varying 
frequency  within  a  minute.  The  pupils  are  contracted 
and  unequal.  The  respiration  varies  in  frequency  and 
depth  and  is  accompanied  by  deep  sighs.  The  apathy 
increases  and  the  next  stage  is  entered.     The  apathy  and 


190  TUBERCULOSIS 

drowsiness  lead  into  a  state  of  perpetual  somnolence, 
from  which,  however,  the  patient  may  be  aroused  ;  the 
child  is  still  able  to  answer  questions,  recognize  its  sur- 
roundings, but  soon  falls  asleep  again.  The  eyes  are  then 
usually  only  half  closed.  Sleep  is  interrupted  by  rest- 
less tossing,  mild  delirium,  or  shrill  outcries — "cri 
hydrencephalique  " — while  the  pulse  and  respiration  still 
maintain  the  above  changes. 

Development,  of  Symptoms  of  Cerebral  Irritation. — 
Converging  strabismus,  which  may  disappear  again  ;  also 
nystagmus.  Dilatation  and  undulation  of  the  pupils, 
that  is,  contracted  when  exposed  to  the  light  and  imme- 
diate dilatation  in  spite  of  the    presence  of  light.     By 


Fig.  64. — Tuberculous  basilar  meningitis.  Five-year-old  boy.  Stage 
of  stupor.  Marked  emaciation  ;  contracted  abdomen  ;  tonic  spasm  of 
both  lower  extremities;  spasm  of  right  hand  in  pronation.  The  left 
arm  was  paralyzed.  Spasms  and  palsies  were  not  permaaeut,  but  alter- 
nated with  each  other. 

ophthalmo.scopic  examination  choked  optic  disk  and 
choroidal  tubercles  are  detectetl.  Loud  gnashing  of  the 
teeth  ;  movements  of  mastication.  A  wandering  move- 
ment of  the  hands ;  twitching  of  the  lips  and  skin. 
Oscillatory  movements  of  the  extremities,  which  are 
lifted  widely  apart.  Kerniffs  sign:  The  leg  when  flexed 
at  the  hip  and  knee  cannot  bo  extended  in  the  sitting 
posture.  The  tendon  and  skin  reflexes  are  increased. 
Tache  cerebrales:  Drawing  the  finger-nail  over  the  skin 
is  followed  by  dark  red  stripes,  which  continue  for  some 
time  (Trousseau). 

The  abdomen  gradually  undergoes  a  scaphoid  retraction 
on  account  of  lack  of  nutrition  and  contraction  of  the 


TUBERCULOUS  MENINGITIS 


191 


Fig.  65.— Tuberculous  basilar  meningitis.  Boy  three  and  a  quarter 
years  old.  8taj;e  of  stupor.  Eyelids  only  partly  closed.  Corne»  are 
beginning  to  dry  up.  Ptosis  of  the  right  eyelid.  Converging  strabis- 
mus. The  lower  jaw  hangs  relaxed  ;  the  nasolabial  folds  have  disappeared 
(paralysis  of  the  labial  and  maxillary  muscles).  Dry  lijis  and  tongue. 
(Clinic  of  Escherich.  Vienna.) 

intestines  (irritation  of  tlie  vagus,  Heubner).     Rigidity 


192  TUBERCULOSrS 

of  the  neck  is  usually  not  very  pronounced.  The  influ- 
ence of  light  upon  the  eyes  lessens  and  soon  ceases 
entirely.  The  somnolence  is  changed  into  stupor.  The 
patient  becomes  wholly  unconscious  and  fails  to  respond 
even  to  the  strongest  stimulation. 

Final  Stage. — At  times  there  is  a  short  return  to  con- 
sciousness just  before  death.  Eyes  half  closed ;  cornea 
insensible  ;  palpebral  fissures  absent ;  flakes  of  mucus  in 
the  eyes  ;  loss  of  sight  and  hearing.  The  pulse  begins  to 
grow  more  rapid,  and  its  frequency  may  reach  200  or 
even  higher  (cardiac  weakness);  its  rhythm  becomes 
regular.  The  respiration  is  of  the  Cheyne-Stokes  type, 
with  long  pauses,  which  may  last  fifty  seconds.  In  con- 
sequence of  the  cardiac  weakness  and  the  insufficient 
oxidation  we  plainly  see  cyanosis,  peaked  nose,  thin  lips, 
and  cold  extremities.  Excessive  emaciation  until  the 
body  is  no  more  than  a  skeleton ;  paralysis  in  the  regions 
supplied  by  the  cranial  nerves,  including  ptosis,  facial 
palsy,  hemi-  and  monoplegic  palsies,  which  may  again 
disappear,  and  be  replaced  by  chronic  or  epileptiform  con- 
vulsions and  extreme  tremor.  Complete  anuria ;  incon- 
tinence of  feces.  Death  often  sets  in  after  days  of  coma. 
The  fever  presents  no  characteristic  curve ;  it  is  higher 
at  the  beginning  than  during  the  rest  of  its  course ;  it 
remits  irregularly  and  rises  in  the  evening,  and  is  always 
of  a  moderate  degree,  but  as  the  end  approaches  it 
frequently  rises  abnormally  high— 41°  or  42°  C.  [105.8°- 
107.6°  F.] — (paralysis  of  the  heat-moderating  center, 
Henoch).     Vomiting  and  constipation  may  be  absent. 

Course  and  Prognosis. — The  prodromata  last  several 
weeks  or  months ;  the  duration  of  the  disease  itself  from 
the  first  vomiting  attack  is  three  weeks  on  an  average, 
but  it  may  be  shorter  or  as  long  as  eight  weeks  (Monti). 
The  somnolent  stage  is  the  longest.  The  development 
of  cerebral  irritation  marks  about  the  middle  of  the 
disease  itself.  The  increase  in  frequency  of  the  pulse 
begins  about  two  and  a  half  or,  at  the  most,  four  days 
before  death.  The  prognosis  is  hopeless.  The  cases  are 
rare  in  which  the  patients  recover  from  the  first  attack 


TUBERCULOUS  MENINGITIS  193 

and  live  long  enough  to  experience  a  second  •  attack,  to 
■which  they  are  sure  to  succumb. 

Diagnosis. — Chief  diaractoristics  :  Vomiting,  independ- 
ent of  the  ingestion  of  food ;  headache  and  constipation 
in  a  child  whose  general  health  and  state  of  nourishment 
have  been  disturl^ed  for  several  weeks.  Abnormally 
slow  and  unequal  indse  and  irregular  respiration.  Grad- 
ual mental  failure,  languor  and  drowsiness,  apathy,  som- 
nolence, and  stupor.  Tuberculosis  in  the  child  itself  or 
in  its  ancestors  strengthens  the  diagnosis.  The  detection 
of  the  tubercle  bacillus  in  the  cerebrospinal  fluid  (by 
centrifuge)  makes  the  diagnosis  positive.  Lumbar  punc- 
ture shows  increased  pressure  of  the  cerebrospinal  fluid, 
which  at  tiie  beginning  is  clear,  but  later  cloudy,  as' if  a 
fine  dust  were  held  in  suspeusion  ;  the  fluid  also  contains 
a  high  and  constantly  increasing  percentage  of  albumin 
(1  to  6  per  cent.,  instead  of  0.2  to  0.4  per  cent,  normally) 
and  mononuclear  leukocytes. 

Possible  Errors. — Typhoid  fever:  Typic  elevation 
of  fever,  splenic  tumor,  roseola,  bronchitis,  meteorism, 
diarrhea,  presence  of  typhoid  bacillus  in  a  drop  of  the 
blood,  or  a  positive  Gruber-Widal  reaction.  Dyspepsia 
or  constipation:  Absence  of  prodromata  and  influence  of 
therapy.  Intestinal  parasites  with  cerebral  irritation: 
Examination  of  stools  ;  administration  of  anthelmintics. 
Hereditary  syphilitic  cerebral  processes :  Coryza,  syphilids, 
and  other  specific  symptoms.      Uremia:   Examine  urine. 

Differential  Diagnosis  between  Various  Forms 
OF  Meningitis. — Epidemic  Cerebrospinal  Meningitis. — 
Acute  onset  without  long  prodromal  stage,  more  intense 
headache,  pronounced  and  painful  stiifness  of  the  neck  and 
s{)iual  column,  hyperesthesia  of  the  skin,  early  somnolence, 
no  abnormal  slowness  or  irregularity  of  the  pulse.  The 
cerebrospinal  fluid  is  made  turbid  by  the  presence  of  pus 
and  contains  the  Meningococcus  intracellularis.  High 
albumin-content  (3  to  6  per  cent.). 

Pundent  Meningitis. — Sudden  onset  with  high  fever, 
convulsions,  and  headache  following  an  injury  to  or  a  sup- 
purative process  of  the  skull.     Slight  stiffness  of  the  neck, 

13 


194  TUBERCULOSIS 

spinous  processes  of  the  vertebrae  not  sensitive  to  pres- 
sure ;  the  spinal  fluid  clouded  with  ])us  and  containing 
polynuclear  leukocytes,  pus  bacteria,  and  no  meningococci. 
It  runs  a  rapidly  fatal  course ;  blood  shows  an  inflam- 
matory leukocytosis. 

Serous  Meningitis. — Spinal  fluid  clear,  sterile,  contains 
more  than  1  per  cent,  of  albumin;  relieved  by  lumbar 
puncture. 

Treatment. — In  case  of  doubtful  diagnosis  give  calomel, 
0.05  gm.,  repeatedly ;  a  leech  applied  to  the  mastoid 
process ;  rub  the  head  with  unguentum  cinereum  or 
unguentum  Crede.  If  syphilis  is  suspected  give  potas- 
sium iodid,  0.5  to  1.5  gm.  per  day  (Fischer).  In  every  case 
darken  the  room  and  prev'cnt  noises  ;  cold  applications 
to  the  head  or  ice-caps,  but  avoid  pressure  ;  for  tiie  head- 
ache give  sodium  bromid  and  ammonium  bromid,  of  each 
5.0  gm.  :  100.0  gm.,  a  cofffeespoonful  three  times  a  day 
(Bendix).  Combat  the  nervousness  and  convulsions  at 
the  beginning  with  warm  baths,  followed  by  a  cold 
douche;  later  give  chloral  hydrate  (1.0  gm. :  50.0  muci- 
lage) in  three  rectal  injections.  Apply  cold  ]>ack  for 
high  fever.  Careful  nursing  of  the  eyes  and  mouth; 
water  cushions  ;  light,  appetizing,  and  varied  diet. 

TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Tuberculosis  seldom  attacks  the  osseous  and  articular 
systems  primarily,  as  a  rule  it  occurs  secondarily  by 
transmission  through  the  circulation  from  a  tuberculous 
gland — as  the  first  manifestation  of  latent  tuberculosis. 
Injuries  are  of  predisposing  influence.  The  affection 
begins  usually  in  the  bones,  and  tiien  extends  by  conti- 
nuity or  by  way  of  the  lymph-channels  to  the  joints.  In 
the  long  bones  the  epiphyses,  and  in  the  short  bones  the 
diapiiyses,  are  especially  liable  to  be  involved. 

Morbid  Anatomy. — The  bones  show  tuberculous  deposits 
in  the  marrow,  chronic  caseating  osteomyelitis,  caseous 
necrosis  of  the  spongiosa,  and  chronic  periostitis.  The 
tubercles  grow  in  size,  undergo  caseation,  and  form  large 
caseous  infiltrations  in  the  spongiosa  with  isolated  frag- 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS     195 

ments  of  necrosed  bone.  These  foci  soften  and  become 
converted  into  cavities  lined  with  granulation  tissue  and 
filled  with  caseous  pus,  in  which  the  bony  sequestra  lie 
free.  Simultaneous  proliferation  of  the  periosteum  causes 
a  thickening  of  that  membrane.  Local  tuberculous  infec- 
tion of  the  periosteum  results  in  superficial  or  deep  caries, 
in  the  formation  of  caseating  j)eriosteal  nodules,  or  in  the 
development  of  cold  abscesses.  These  usually  rupture 
externally  by  means  of  fistulae,  either  at  the  site  of  their 
origin  or,  tunneling  through  the  tissue,  they  appear  in  an 
altogether  diflPerent  location. 


Fig.  66. — Spiua  ventosa  of  the  right  thumb  and  left  middle  finger  of 
a  three-year-old  child. 

In  the  joints  we  note  the  eruption  of  disseminated 
tubercles  on  the  synovial  membrane;  the  latter  is  con- 
verted into  a  hyperemic,  infiltrated,  or  soft  grayish-red 
granulation  tissue,  which  is  permeated  with  tubercles — 
arthritis  fnnf/osa ;  a  serofibrinous  or  pus-like  exudate 
fills  the  articular  cavities.  The  surrounding  soft  parts 
are  edematous  and  infiltrated,  the  skin  pale,  smooth,  and 
shiny — tumor  a/bus ;  development  of  cold  abscesses  and 
fistulous  tracts. 

The   constitutional   disturbance   in   the  mild  cases  is 


196  TUBERCULOSIS 

slight,  but  in  all  severe  forms,  es[)ecially  in  re})oated 
attacks,  it  is  considerable  and  simulates  general  tubercu- 
lous infection.  The  course  is  always  prolonged.  Cure 
(relative)  is  possible  in  all  stages,  but  is  usually  accom- 
panied by  anomalies  of  position  and  function.  Tendency 
to  recurrences.  Constant  danger  of  general  tuberculosis, 
meningitis,  etc. 

The  most  important  symptoms  of  bone  and  joint  tuber- 
culosis are : 

SPINA  VENTOSA 

This  is  a  tuberculous  osteomyelitis  of  the  phalanges, 
consisting  of  a  suppurative  absorption  and  enlargement 
of  the  marrow  spaces  accompanied  by  a  simultaneous 
periosteal  bone  formation.  This  causes  a  swelling  of  the 
bone. 

Clinical  Symptoms. — A  slowly  developing,  painless, 
spindle-shaped  swelling  of  the  shaft  of  the  bone ;  the 
skin  becomes  red  and  thin  ;  eruption  occurs  and  fistulae 
are  formed. 

Treatment. — Compress  with  circular  bands  of  adhesive 
plaster,  iodovasogen,  comfortable  position ;  surgical  inter- 
vention to  remove  diseased  tissue  ;  in  severe  cases  disar- 
ticulation.    Spontaneous  cure  is  possible. 

SPONDYLITIS.  TUBERCULOUS  CARIES  OF  THE  VERTEBR/E 

{Poll's  Disease) 

This  consists  of  tuberculous  inflammation  and  caries 
of  a  single  vertebra  or  of  the  intervertebral  disks ;  the 
lower  dorsal  or  the  lower  cervical  vertebrse  are  usually 
involved.  The  spinal  column  breaks  down  gnidually  or 
suddenly  (by  pressure  from  above).  A  pointed,  and  in 
case  of  disease  of  several  vertebrse  a  rounded,  hump 
results — "  gibbus."  The  pus  which  collects  in  the  neigh- 
borhood of  the  diseased  bone  seeks  to  gravitate  externally; 
in  caries  of  the  cervical  vertebrje  it  appears  as  a  retro- 
pharyngeal abscess ;  in  disease  of  the  dorsal  vertebrae  it 
travels  down  along  the  spinal  column  to  the  lower  portion 
of  the  pelvis  and  back,  and  most  frequently  forms  a 
typic  psoas  abscess  at  the  inner  side  of  the  femur. 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS    197 

Symptoms. — Vague  pains  in  the  spine,  disinclination 
to  walk  and  stand,  frequent  desire  to  lean  against  objects. 


Fig.  C7. — Tuberculous  caries  of  a  vertebral  body  (spondylitis),  with 
the  formation  of  a  psoas  abscess. 

Gmduiil  stiffening  of  the  spinal  column,  which  is  espe- 
cially noticable  at  an  early  stage  when  picking  an  object 
up  from  the  floor.  Localized  pressure  tenderness  when 
the  spinous  processes  are  jjaljxited  ;  a  gradual  or  rapid 


198  TUBERCULOSIS 

Fig.  68. — Spondylitis  of  the  upper  dorsal  vertebra}.  Sharp-angled 
kyphosis.  This  eight-year-old  gir!  showed  phenomena  of  transverse 
myelitis  (spastic  paraplegia  of  the  legs  with  increased  reflexes),  which 
under  orthopedic  management  disappeared,  with  the  cure  of  the  spondy- 
litis.    (Clinic  of  von  Banke-Herzog,  Munich.) 

development  of  any  one  of  these  symptoms.  Formation 
of  a  more  or  less  pointed  luimp,  which  does  not  disappear 
when  the  patient  lies  on  the  abdomen.  As  the  process 
progresses  the  symptoms  of  tlie  general  disease  gradually 
arise.  In  severe  cases  extension  of  the  inflammation  or 
compression  of  the  spinal  cord  leads  to  manifestations  of 
myelitis,  which  varies  according  to  the  height  of  the  dis- 
eased area.  In  cervical  spondylitis  disturbances  of 
swallowing  and  speech  als6  co-exist. 

Results. — Cure,  with  a  remaining  large  or  small  hump  ; 
death  due  to  exhau.stion,  amyloid  disease,  peritonitis, 
general  tuberculosis,  myelitis,  or  meningitis.  The  treat- 
ment should  strive  to  relieve  pressure  and  to  set  the 
spinal  column  at  rest  by  means  of  extension  beds  and 
orthopedic  cor.sets ;  also  general  hygienic  management. 
Osteomyelitis  and  periostitis  of  the  long  bones,  of  the 
malar  bones,  of  the  temporal  bones,  orbital,  etc.,  are 
manifested  by  chronic  swellings,  cold  abscesses,  fistulous 
tracts,  and  caries. 

Treatment. — Where  possible,  make  alcoholic  applica- 
tions, maintain  rest,  inject  iodoformol. 

COXITIS 

Coxitis  is  a  tuberculous  inflammation  of  the  hip-joint, 
which  is  usually  an  extension  from  the  bony  portions  of 
the  joint.^ 

Symptoms. — At  first  there  is  a  slight  dragging,  later  a 
pronounced  favoring  of  the  diseased  leg  and  over  use  of 
the  healthy  leg — voluntary  limping ;  pressure  tenderness 
at  the  trochanter ;  pains  in  the  knee;  diminished  mobility 
of  the  hip-joint.  The  leg  is  held  contracted,  at  first  in 
abduction,  flexion,  and  external  rotation,  with  apparent 
elongation ;  later  in  adduction,  flexion,  and  internal  rota- 
tion, with   apparent   shortening.     Wiien    an   attempt  is 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS     199 


Fio.  <)8. 


200 


TUBERCULOSIS 


made  to  extend  the  flexed  leg,  with  the  patient  in  the 
dorsal  posture,  the  spine  is  lifted  and  becomes  lordosed 


Fig.  69.— Dorsal  spondylitLs,  wiili   the  Ibrmatioii  of  an  ab.sces8  at  the 
samiuit  of  the  hump. 

and  the  pelvis  moves  with  the  joint;  when  attempting  to 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS     201 

flex  the  leg  the  pelvis  is  raised  and  the  lordosis  disap- 
pears. Interference  with  posteriorrotationof  the  affected 
leg  is  also  of  importance ;  this  is  tested  for  by  grasping 
the  tip  of  the  foot  and  rotating  first  one  leg,  then  the 
other,  while  the  patient  is  in  the  recumbent  position. 
The  process  progresses  with  swelling  of  the  hip  and 
gluteal  regions  and  with  the  development  of  burrowing 
abscesses,  which  commonly  rupture  at  the  posterior  and 
outer  side  of  the  femur. 

Treatment. — Rest  by  means  of  plaster-of-Paris  cast ; 
permanent  extension.  As  soon  as  possible  institute  such 
orthopedic  procedures  as  will  permit  the  child  to  walk, 
and  yet  correct  the  deformity  and  transmit  the  support  of 
the  body  weight  to  the  pelvis.  The  general  disease  is 
treated  by  sojourn  in  the  open  air  and  at  the  seacoast. 
The  disease  may  be  cured  at  any  stage  ;  the  prognosis  in 
the  early  stages  is  the  most  favorable,  while  in  the  more 
advanced  periods  the  cure  is  only  relative  and  is  accom- 
panied by  deformities,  ankylosis,  and  pseudo-arthrosis. 

TUBERCULOSIS  OF  THE  KNEE-JOINT  ("WHITE  SWELLING" 
OF  THE  KNEE) 

Tuberculous  disease  of  the  knee-joint  begins  with  stiff- 
ness, lessened  mobility,  and  slight  pains.  Early  swelling 
of  the  joint  may  be  recognized  by  the  disappearance  of 
the  two  fossae  at  the  sides  of  the  patellar  tendon,  as  well 
as  by  filling  out  of  the  popliteal  space.  Later  the  knee 
is  flexed  and  becomes  painful  when  moved,  and  also  spon- 
taneously. The  growing  swelling  assumes  a  spindle  form, 
is  elastic,  and  its  skin  covering  is  shiny  and  stretched  ; 
there  is  fluctuation  or  pseudofluctuation  ;  the  patella  be- 
comes immobile.  The  development  of  an  abscess  increases 
the  size  of  the  swelling  considerably  and  causes  severe  pain; 
the  abscess  ruptures  in  the  region  of  the  joint  itself  or  in 
that  of  the  femur  or  the  tibia.  Destruction  of  the  joint 
leads  frequently  to  subluxation  and  luxation  of  the  tibia 
backsvard.  Healing  is  possible  in  all  stages,  but,  as  a 
rule,  connective-tissue  overgrowth  or  true  bony  ankylosis 
results. 


202 


TUBERCULOSIS 


PLATE  20 

Fig.  1.  Tuberculosis  of  the  knee-joint,  which  led  to  destruction  of 
the  joint  and  subluxation  of  the  tibia.  Tuberculous  osteomyelitis  and 
periostitis  of  the  tibia,  with  multiple  fistulous  tracts. 

Fig.  2.  Tuberculosis  of  the  Knee-joint.— Disappearance  of  the  con- 
tour of  the  joint.  Doughy  swelling  at  the  anterior  aspect  of  the  knee 
covered  by  tense,  pale  skin.  Fistula  formation.  Subluxation  of  the 
tibia. 


Treatment. — Place  at  rest  in  plaster-of-Paris  cast  in  the 
position  of  flexion.     Inject  iodoformol ;  later  apply  port- 


FiG.  70.— Tuberculosis  of  the 
right  ankle-joint,  with  doughy 
swelling  of  the  joint  and  disappear- 
ance of  the  bony  contours. 


Fig.  71. — Tuberculous  caries  of 
the  left  tarsjxl  bones,  with  the 
formation  of  a  fistula. 


able  apparatus,  with  the  support  at  the  tuberosity  of  the 
ischium. 


7 ah.  2a. 


lig.l. 


Fig.^. 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS     203 

TUBERCULOSIS  OF  THE  JOINTS  OF  THE  FEET  (TUMOR  ALBUS  PEDIS) 

The  ankle-joint  is  the  one  most  commonly  involved. 
It  is  accompanied  by  localized  pain  in  front  and  at  the 
sides  of  the  foot  on  standing,  which  later  may  also  occnr 
spontaneonsly.  The  tissne  in  front  and  back  of  each 
bone  is  somewhat  swollen  and  the  bony  contours  are  lost. 
Later  a  distinct  and  diffnse  elastic  .swelling  is  noted  aronnd 
the  joint;  snppnration,  cold  abscesses,  fistnla  formation. 

Treatment. — Pntatrest.  Alcohol  applications..  lodo- 
formol. 


TUBERCULOSIS  OF  THE  ELBOW 

Pain,  interference  with  movement,  and  spindle-shaped 
swelling,  which  forms  a  marked  contrast  to  the  emaciated 
upper  forearm.  The  forearm  is  flexed  midway  between 
pronation  and  supination. 


DISEASES  OF  THE  NERVOUS  SYSTEM 

DISEASES  OF  THE  BRAIN  AND  ITS  MEMBRANES 
CEREBROSPINAL  MENINGITIS 

Cerebrospinal  meningitis  is  an  epidemic  and  sporadic 
suppurative  inflammation  of  the  cerebrospinal  meninges, 
which  attacks  by  preference  young  children  and  nursing 
infants ;  its  direct  cause  is  the  Meningococcus  intracellu- 
laris.  This  is  similar  to  the  gonococcus,  inasmuch  as  it 
occurs  in  pairs,  and  is  found  in  groups  of  twenty  or  more 
pairs  within  the  cell.  It  is  stained  by  methylene-blue, 
but  in  the  meningeal  exudate  it  fails  to  stain  by  Gram's 
method,  whereas  it  may  be  detected  by  means  of  Gram's 
stain  in  smear-cultures.  It  grows  in  glycerin-agar ; 
when  it  is  injected  intradurally  into  goats  it  sets  up  a 
typic  case  of  meningitis  (Heubner) ;  the  meningococcus 
has  been  demonstrated  in  the  nasal  discharge  of  patients 
suifering  from  meningitis. 

Morbid  Anatomy. — Hyperemia  of  the  cranium  and  of 
tlie  meninges  of  the  brain  and  spinal  cord.  A  gelatinous, 
serous,  fibrous,  or  purulent  exudate  collects  between  the 
pia  and  arachnoid,  preferably  at  the  convexity  between 
the  convolutions,  and  at  the  posterior  surface  of  the  cer- 
vical and  limibar  spine.  The  brain  appears  as  if  it  were 
"smeared  with  butter."  Inflammation  and  softening  of 
the  superficial  portions  of  the  brain.  A  cloudy,  seropuru- 
lent  exudate  fills  the  ventricles. 

Symptoms. — Its  onset  is  sudden  during  the  enjoyment 
of  perfect  health,  or  it  begins  after  a  short  period  of  pro- 
dromal symptoms,  consisting  of  weakness  and  loss  of 
appetite,  with  a  high  fever,  convulsions,  vomiting,  ex- 
treme pains  in  the  neck  and  back,  accompanied  by  loud 
sighing.  Extreme  hypersensitiveness  to  movement,  light, 
and  noise.     The  cardinal  symptoms  are  :  Intense  stiflPness 

204 


CEREBROSPINAL  MENINGITIS  205 

of  the  neck  and  of  the  spine — opisthotonos.  Spasms  of 
the  extensor  muscles  of  the  extremities,  followed  finally  by 
tonic  rigidity  of  the  whole  body.  There  is  also  an  early 
clonic  twitching  and  tremor  in  the  various  groups  of  mus- 
cles ;  nystagmus  (Kernig's  symptom).  Partial  palsy  of 
the  lower  extremities,  of  the  muscles  supplied  by  the 
facial  nerve,  and  of  the  ocular  muscles.  Consciousness 
is  soon  lost  and  the  patient  enters  a  somnolent  stage, 
which  is  interrupted  by  shrill  cries  and  jactitation.  The 
pupils  are  contracted  and  the  abdomen  retracted.  Herpes 
fiicialis  (in  50  per  cent.),  various  erythemata,  i)etechi8e, 
and  urticaria.  The  pulse  and  respiration  rate  are  usually 
considerably  increased.  At  times  the  former  is  irregular, 
and  later  in  the  course  of  the  disease  it. becomes  slower 
than  normal.  The  fever  rises  rapidly  to  40°  C.  [104°  F.] 
and  over,  and  is  irregularly  remittent  or  intermittent. 

Course. — Very  acute  cases  are  sometimes  met  with 
which  run  a  course  of  only  a  few  hours  or  days,  accom- 
panied by  a  sudden  loss  of  consciousness,  convulsions, 
subnormal  or  hyperpyretic  temperature,  and  apoplecti- 
form palsies.  In  contradistinction  we  meet  abortive 
forms,  presenting  a  headache,  moderate  cervical  rigidity, 
and  fever,  which  frequently  cannot  be  recognized  except 
during  an  epidemic.  The  average  course  is  protracted 
over  weeks  and  months  and  associated,  as  a  rule,  with 
remissions  and  fresh  relapses.  Convalescence  sets  in 
gradually  and  is  considerably  protracted;  individual  symp- 
toms may  persist  for  a  long  time.  Cerebral  disturbances, 
deafness,  blindness,  hydrocephalus,  and  psychoses  are 
frequently  the  after-effects  of  this  disease.  For  this 
reason  and  on  account  of  the  high  mortality  rate  (60  to 
70  ])er  cent.)  the  prognosis  must  be  doubtful.  Death 
occurs  during  coma,  or  on  account  of  cardiac  weakness, 
or  because  of  complications,  such  as  disease  of  the  lungs, 
intestines,  heart,  kidneys,  etc. 

Treatment. — Absolute  rest.  Prevent  external  irrita- 
tions; carefully  selected,  appetizing  diet.  Hot  baths 
(35°  to  40°  C.  [95°-104°  F.]  ),  with  cold  applications 
to  the  head  once  or  twice  a  day.-  To  relieve  the  i)ressure 


206    DISEASES  OF  THE  BRAIN  AND  ITS  MEMBRANES 

|>erform  lumbar  puncture  ;  re|>eat  every  few  clays.  A])ply 
unguentum  Crede  to  the  neck,  temples,  and  back.  Sub- 
cutaneous infusions  of  sublimate  (0.005  to  0.01  gm.  per 
day)  in  the  glutt'al  region,  daily  at  the  beginning,  later, 
every  two  days  (Dazia,  Consalvi).  Keep  nose  clean  by 
bathing. 

PURULENT  MENINGITIS  ;    SIMPLE  MENINGITIS 

Purulent  meningitis  is  a  suppurative  inflammation  of 
the  membranes  of  the  brain  caused  by  injuries  to  the 
skull,  extension  of  suppurative  processes  in  the  middle 
ear,  nose,  etc.  The  direct  cause  is  one  of  the  various 
micro-organisms,  especially  the  pneumococcus,  strepto- 
cocci, and  staphylococci,  the  bacillus  of  influenza,  colon 
bacillus,  typhoid,  and  pyocyaneus.  It  attacks  children 
at  any  age  or  of  any  constitution. 

Morbid  Anatomy. — The  convexity  of  the  brain  is  cov- 
ered, as  if  by  a  hood,  with  a  yellowish-green,  ])uru- 
lent,  seropurulent,  or  fibrinous  exudate,  which  lies  in  the 
subarachnoid  space.  The  adjacent  portions  of  the  brain 
are  inflamed  and  a  turbid  fluid  is  found  in  the  ventricles ; 
the  latter  may,  however,  be  absent. 

Symptoms. — Sudden  onset ;  chills,  vomiting ;  high  fever 
(40°  C.  [104°  F.]  ) ;  severe  convulsions  of  a  tonic  and 
clonic  character,  which  appear  at  intervals;  loss  of  con- 
sciousness; expanded  fontanels  in  nurslings;  puj)ils  con- 
tracted and  uncipud ;  staring  eyes;  torturing  headache; 
great  thirst;  rigidity  of  the  neck;  Kernig's  symptom; 
temporary  erythema.  The  pulse  and  respiration  rate  are 
extraordinarily  rapid;  incontinence  of  feces  and  urine. 
Death,  at  the  latest,  at  the  end  of  a  week.  Very  rarely 
the  patient  recovers  after  a  prolonged  convalescence, 
which  is,  however,  nearly  always  followed  by  permalient 
sequela?.     The  prognosis  is,  therefore,  serious. 

Diagnosis. — Meningitis  is  diff^crentiated  from  acute  in- 
fections by  the  following  symptoms :  Expanded  fonta- 
nels; severe  headache;  Kernig's  symptom,  and  pupillary 
contraction. 


THROMBOSIS  OF  THE  CEREBRAL  SINUSES     207 

Treatment. — Prevent  external  irritation  ;  ice-cold  or 
hot  apjilications ;  hot  baths  ;  leeching  ;  laxatives  (calomel, 
rhubarb) ;  febrile  diet ;  lumbar  puncture  to  relieve  the 
pressure. 

SEROUS  MENINGITIS.    MENINGISMUS 

Serous  meningitis  consists  of  an  infiltration  of  the  pia 
and  the  presence  of  a  cleJir  serous  fluid  in  the  ventricles, 
which  is  accompanied  by  the  symptoms  of  meningitis. 
It  occurs  in  tumors  and  injuries  of  the  skull,  as  the 
termination  of  acute  infections  and  gastro-intestinal  dis- 
eases, and  in  otitis  media.  The  symptoms  are  those  of  a 
meningitis,  but  show  no  specific  characteristics ;  some- 
times they  simulate  the  epidemic  form,  sometimes  the 
tuberculous  or  purulent  meningitis.  The  course  is,  how- 
ever, usually  favorable. 

Treatment. — Repeated  lumbar  punctures.  [It  is  doubt- 
ful if  this  form  of  treatment  would  receive  unanimous 
approval  from  clinicians.  True  serous  meningitis  tends 
to  spontaneous  recovery. — Ed.] 

The  spinal  cord  may  be  involved  in  every  form  of 
meningitis,  and  this  extension  may  be  recognized  by  the 
following  manifestations :  Rigidity  of  the  spine,  muscu- 
lar twitcliing  in  the  extremities,  hyperesthesia  of  the 
skin,  and  paralysis  of  the  bladder  and  rectum. 

THROMBOSIS  OF  THE  CEREBRAL  SINUSES 

The  following  forms  of  thrombosis  are  distinguished  : 
Inflammatory  thrombosis,  following  extension  from  per- 
ipheral purulent  processes,  mostly  from  caries  of  the 
petrous  portion  of  the  temporal  bone,  head  wounds,  and 
eczema.  The  petrous  and  transverse  sinuses  are  most 
frequently  involved,  more  rarely,  the  cavernous  and 
longitudinal  sinuses. 

Marantic  thrombosis,  following  interference  with  the 
circulation  by  tumors  of  the  skidl  and  brain,  or  from 
slowing  of  the  blood-current  in  exhausting  diseases ;  the 
longitudinal  sinus  is  the  one  most  frequently  involved. 
In  many  cases  a  bacterial  i)hlebitis  is  also  the  cause. 


208   CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 

Morbid  Anatomy. — The  diseased  sinus  is  felt  as  a  tense, 
thickened  cord,  which  contains  at  a  certain  point  an 
adherent  thrombotic  mass,  whose  appearance  and  con- 
sistency vary  with  age  and  cause ;  thus  it  may  be 
homogeneous  or  stratified,  red,  gray,  or  yellow  ;  hard  or 
soft,  also  purulent.  Not  rarely  there  is  also  a  thrombosis 
of  neighboring  veins,  hyperemia,  and  also  hemorrhages 
of  the  meninges  and  the  brain. 

Symptoms.  —  The  char'acteristic  symptoms  are  few. 
Manifestations  of  a  cerebral  disease,  including  convul- 
sions, muscle  palsies,  etc.  Signs  of  general  sepsis  are 
often  present.  Of  the  local  symptoms  the  following  are 
important :  Bulging  of  the  previously  sunken  fontanels  ; 
hemorrhagic  condition  of  the  spinal  fluid  which  has  been 
obtained  by  lumbar  puncture ;  extension  of  the  throm- 
botic process  to  the  jugular  vein ;  unilateral  swelling  of 
the  eyelids  and  face ;  i)rotruding  eyeballs  (cavernous  sinus), 
cyanosis  of  face  and  forehead  (longitudinal  sinus) ;  one 
jugular  less  full  of  blood  than  the  other,  and  swelling  of 
the  mastoid  process  (transverse  sinus).  The  result  is 
usually  fatal ;  cure  with  remaining  defects  is  possible  in 
marantic  thrombosis  (permanent  disturbances  of  cere- 
brum). Operative  treatment  of  otitic  thrombosis  some- 
times gives  good  results;  other  treatment  consists  in 
applying  antiphlogistics  and  in  depleting  the  part. 


CIRCULATORY    DISTURBANCES  OF  THE   BRAIN 

HYPEREMIA 

Active  hyperemia  follows  increase  of  arterial  blood- 
pressure  in  traumatism,  sunstroke,  at  the  beginning  of 
the  acute  infectious  diseases,  in  meningitis,  alcoholic 
intoxications,  psychic  excitement,  and  dentition. 

Symptoms. — Hot,  flushed  head,  reddened  eyes,  head- 
ache, ringing  in  the  ears,  artexial  pulsation,  vomiting, 
excitement,  delirium,  somnolence,  coma,  and  increased 
pulse  rate. 

Treatment  of  Active  Hyperemia. — Antiphlogistics ;  leech- 


CHRONIC  HYDROCEPHALUS  209 

ing  back  of  the  ear ;  ice-caps  ;  depletion  by  purging  with 
calomel  or  compouiul  infusion  of  senna. 

Passive  hyperemia  is  due  to  venous  obstruction  in  pul- 
monary and  cardiac  diseases,  struma,  whooping-cough, 
spasm  of  the  glottis,  or  holding  of  the  head  in  bent 
position. 

Symptoms. — Languor,  drowsiness,  cyanosis,  weak  ten- 
sion of  pulse,  and  expanded  fontanels. 

Treatment  of  Passive  Hyperemia. — Treat  the  causal  con- 
dition ;  administer  stimulants — camphor,  alcoholics. 

ANEMIA 

Cerebral  anemia  occurs  in  acute  loss  of  blood,  in  car- 
diac weakness,  and  as  an  associated  phenomenon  of  the 
various  forms  of  anemia. 

Symptoms. — Pallor  of  the  face  ;  tossing  of  the  head  to 
and  fro,  numbness  ;  eyes  rotated  upward  ;  cloudiness  of 
corneae ;  tonic  contractures  of  the  extremities  which  are 
usually  in  position  of  flexion  ;  the  fontanels  are  retracted 
(in  contradistinction  to  hydrocephalus  and  meningitis) ; 
the  pulse  is  small  and  very  rapid ;  the  respiration  is  in- 
creased in  rapidity  and  the  temperature  is  low. 

A  peculiar  form  of  cerebral  anemia  is  the  hydrocepha- 
loid  (Marshall  Hall).  This  is  a  cerebral  state  which  fol- 
lows the  loss  of  considerable  fluid  in  an  exhausting  intes- 
tinal catarrh,  which  is  characterized  anatomically  by 
anemia  and  a  watery  condition  of  the  brain  without  the 
collection  of  fluids  in  the  ventricles. 

Treatment. — External  and  internal  stimulation  ;  infu- 
sion of  normal  salt  solution  hypodermically  and  by  rectum. 
(See  also  Cholera  Infantum.) 

CHRONIC  HYDROCEPHALUS 

Chronic  hydrocephalus  is  a  condition  due  to  the  collection 
of  an  abnormal  amount  of  fluids  within  the  skull,  either 
in  tiie  cerebral  ventricles  {hydrocephalus  internm)  or  be- 
tween the  dura  and  arachnoid  [hydrocephalus  extirnus  or 
14 


210  CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 

FIGURE  72 

AtropMc  Brain  in  Hydrocephalus  Extemus.— Boy    two  and  a  lialf 
mouths  old.     (For  explanation,  see  Fig.  73.) 


Fio.  73. — Hydrocephalus  externiis  v...iij;t mUn,.  x  i.m..iim>  ui..-  to 
congenital  syphilis.  Boy  two  and  a  half  months  old.  The  child,  which 
was  born  spontaneously,  showed  a  rapid  increase  in  the  size  of  the  skull ; 
at  the  age  of  oue  month  he  was  picked  up  by  an  ambulance  while  suffer- 
ing from  eclampsia  infantum.  On  examination  he  wa.s  found  to  have 
tonic  spasms  of  the  arms  and  legs;  the  circumference  of  his  head  was 
40.5cm.  [16.4in.]  (normal  35.4  cm.  [14.3  in.]);  the  large  foutaiicl.  which 
measured  11X13  cm.  [4.4X5.4  in.],  was  bulging,  enlarged,  and  considerably 
expanded,  and  its  edges  irregular,  rough,  and  notched.  A  lumbar  punc- 
ture was  performed  and  40  ccm.  of  a  clear,  sterile  fluid  was  removed, 
which  showed  a  specific  gravity  of  1.000  and  an  albumin-content  of  1 
per  cent.  A  tenijwniry  improvement  resulted.  The  child  was  lost  to 
observation  and  died  at  the  ago  of  two  and  a  half  months  from  broncho- 
pneumonia. At  necropsy  (JOO  ccm.  of  fluid  were  removed  from  the  sub- 
dural space.  The  brain  was  atrophied  and  lay  on  the  floor  of  the  skull, 
compressed  to  the  size  of  a  woman's  fist  (see  PMg.  72).  It  had  lost  its  nor- 
mal shape.  Numerous  tense  connective-tissue  strands  extended  from  its 
surface  to  the  dura  in  the  region  of  the  large  fontanel.  Other  conditions 
which  were  found  were  a  bronchopneumonia  and  enlargement  and  con- 
solidation of  the  spleen  and  liver ;  the  latter  was  discolored  greenish 
yellow. 


Fig.  72. 


CHR ONIC  HYDROCEPHA  LUS  211 

intrameningcalis) ;  the  latter  form  is  by  far  the  rarer. 
Hydrocephalus  is  either  congenital  or  acquired. 

Etiology. — The  internal  form  of  hydrocephalus  occurs 
passively  through  obstruction  to  the  outflow  of  the  cere- 
bral venous  blood  on  account  of  pressure  upon  the  vein  of 
Galen,  or  it  may  occur  actively,  following  inflammatory 
disease  of  the  ventricular  ependyma  and  choroid  plexus. 
The  external  form  of  hydrocephalus  is  the  result  either 
of  intra-utorine  or  acquired  inflammatory  processes  of 
the  dura  and  arachnoid,  or  it  arises  on  account  of  imper- 
fect development  of  the  brain  (agenesis).  The  true 
causes  of  these  various  changes  are  unknown.  Of  etiologic 
significance  are :  Congenital  syphilitic  disease  of  the  ves- 
sels and  ependyma;  rachitis;  brain  tumors,  especially 
when  located  at  the  base  ;  cervical  and  mediastinal  tumors ; 
meningitis;  traumatism;  pertussis;  acute  infectious  dis- 
eases ;  disturbances  in  development  of  the  adrenal  bodies 
(Czerny).  It  frequently  occurs  in  neuro-  and  psychopathic 
families.  The  acquired  form  of  liydrocephalus  may 
develop  before  as  well  as  after  the  cranial  bones  have  be- 
come fully  ossified. 

3Iorbid  Anatomy. — Enlarged  skull ;  gaping  sutures ; 
thin  and  partially  membranous  cranial  walls;  flattening 
of  the  orbital  roofandof  the  sella  turcica.  In  hydro- 
cephalus externus  the  space  between  the  dura  and  arach- 
noid is  filled  with  a  fluid  which  connects  the  two  mem- 
branes by  means  of  tense  threads  and  cords.  The  small 
pear-shaped  brain  lies  on  the  floor  of  the  cranial  cavity 
undeveloped,  or  perfectly  formed  but  compressed.  In 
hydrocephalus  internus  the  convolutions  are  flattened,  the 
hemispheres  fluctuate,  the  lateral  and  fourth  ventricles  are 
distended  with  fluid,  and  in  some  severe  cases  the  hemi- 
spheres are  converted  into  large,  thin-walled  cysts.  The 
brain  substance  is  atrophied.  The  fluid  is  colorless  or  a 
light  green,  it  contains  a  small  amount  of  albumin  {),  per 
cent.),  and  occurs  in  amounts  varying  from  100  gm.  to  2 
liters  [4.4  pints]  and  even  more  (as  many  as  36  liters 
[79  pints]  have  been  observed). 

Symptoms. — Congenital   hydrocephalus   may   interfere 


212  CIRCULATORY  DTSTURBANCES  OF  THE  BRAIN 


CHRONIC  HYDROCEPHALUS 


213 


214    CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 

Fig.  76. — Congenital  chronic  hydrocephalus;  sacral  spina  bifida. 
Marked  tonic  spasms  of  all  four  extremities.  Opisthotonos.  Photo- 
graphed two  days  before  death.     (Clinic  of  Escherich,  Vienna.) 


with  birth  or  it  may  not  become  noticeable  until  after 
birth.  The  chief  symptom  is  the  constant  increase  in 
size  of  the  skull,  which  in  a  fully  developed  case  of 
hydrocephalus  presents  the  following  characteristics  :  The 
skull,  which  is  increased  on  all  sides,  presents  a  marked 
contrast  with  the  small  and  senile  face  ;  the  forehead 
bulges  forward  ;  the  occipital  bone  is  more  horizontal  than 
normal  and  tiie  temporal  and  parietal  bones  project  later- 
ally. The  large  fontanel  is  wider  than  normal,  it  is  tense 
and  pulsates  actively  ;  the  sutures  gape  and  the  bony 
plates  are  soft.  Sutures  which  had  closed  may  again 
open ;  veins  congested  and  feel  elastic  ;  protruding  eyes ; 
a  staring,  downcast  expression  of  the  eyes,  with  the  white 
sclera  visible  from  above.  Frequently  the  children  are 
unable  to  support  their  head.  The  body  may  be  im})er- 
fectly  developed;  the, nourishment  is  poor,  the  skin 
inelastic,  yet  the  ai)petite  is  retained  and  the  digestion  is 
good.  Although  the  eyes  are  usually  badly  affected 
(strabismus,  nystagmus,  choked  disk,  atropiiy  of  optic 
nerve,  blindness),  yet  the  other  organs  of  special  sense 
remain  intact. 

Disturbances  of  Motion. — Tremor  and  choreic  move- 
ments in  the  upper  extremities  and  a  spastic — more  rarely 
a  paretic — condition  of  the  lower  extremities.  Con- 
tractures, convulsive  twitching  of  single  muscle  groups, 
and  true  eclamptic  attacks  may  arise  at  any  stage  of  the 
process,  A  spastic  rigidity  of  the  tendons,  esjjecnally  in 
the  legs,  is  characteristic  of  the  beginning  of  the  disease 
(v.  Ranke).  There  is  faulty  development  or  retrogression 
of  the  psychic  function,  resulting  in  various  degrees  of 
idiocy. 

Course. — The  course  is  chronic  and  ])rogresses  with  an 
increase  in  the  circumference  of  the  skull  and  the  various 
physical  and  mental  changes.  Death  is  brought  on  by 
eclampsia,  collapse,  or  intercurrent  diseases.     More  rarely 


/ 


Fig.  76. 


215 


216   CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 


Fig.  77. — Chronic  hydrocejiliiilus  wliidi  lias  run  its  coarse.  Imbe- 
cility ;  adenoid  vegetations.  Boy  nine  years  old.  Born  prematurely, 
between  seven  and  eight  mouths.  The  head  was  observed  to  be  too 
large  immediately  after  birth  ;  the  fontanels  closed  in  three  years.  No 
convulsions.  Was  taught  to  walk  when  two  years  old,  but  lost  the 
faculty  (rachitis),  and  did  not  again  learn  to  walk  until  the  fifth  year. 
Unable  to  talk  correctly  until  six  years.  Much  headache.  The  boy  is 
now  attending  the  first  school  class  for  the  second  time,  and  is  making  but 
tolerable  headway.  Of  a  phlegmatic  yet  fearful  disposition.  The  facial 
expression  is  somewhat  stupid  on  account  of  the  adenoid  vegetations. 
The  cranium  is  enlarged  and  its  protuberances  are  prominent ;  the  mouth 
is  held  open  ;  mild  convergent  strabismus.  Carious  teeth  (see  Fig.  39) ; 
pointed  palate. 

the  disease  may  take  the  following  courses :  Spontaneous 
cure  may  occur,  but  only  when  the  fluid  which  has  col- 


CEREBRAL  INFANTILE  PALSY  217 

lected  is  small  in  amount ;  the  condition  may  also  remain 
at  a  standstill  with  a  gradual  further  development  of  the 
intellect ;  rupture  externally,  either  through  the  nose, 
eyes,  ears,  or  fontanels,  may  lead  to  a  cure. 

Diagnosis. — This  is  impossible  in  mild  cases;  in  doubt- 
ful cases  it  is  important  to  take  regular  measurements  of 
the  head. 

Treatment. — If  syphilis  is  suspected,  resort  to  sjjecific 
treatment  externally  and  internally,  with  mercury  or 
potassium  iodid.  Lumbar  piuicture  repeated  every  few 
weeks,  with  the  removal  of  small  amounts  of  fluid,  about 
30  cc.  (Bokay).  Puncture  the  lateral  ventricles  by  way 
of  the  large  fontanel  to  one  side  of  the  .middle  line  by 
means  of  a  trocar  or  aspirating  needle  and  inject  tincture 
of  iodin  (Pott,  von  Ranke,  Phokas,  Gross) ;  paracentesis 
with  drainage  (Biedert) ;  suitable  training  and  methodic 
teaching ;  carry  out  rides  of  general  hygiene. 

ENCEPHALITIS 

The  following  forms  of  encephalitis  may  arise  : 
Acute,  non-suppurative  encephalitis,  with  cerebral  irrita- 
tion,   convulsions,    fever,    etc.       The    prognosis    is    not 
unfavorable.     Many  of  the   favorable   forms  of  cerebral 
irritation  without  paralysis  belong  to  this  division. 

Acute  suppurative  encephalitis  (brain  abscess)  follows 
injuries  to  tiie  skull,  suppuration  in  the  head,  especially 
of  tiie  ear,  and  septicemia.  The  onset  is  sudden  and  is 
accompanied  by  fever  and  general  meningitic  symptoms, 
together  with  focal  phenomena.  The  ditFerentiation  of 
brain  tumor  from  meningitis  is  difficult.  Treatment  is 
operative  when  the  exact  site  is  known ;  otherwise  it  is 
that  of  meningitis. 

CEREBRAL  INFANTILE  PALSY 

This  is  no  uniform  disease  process  ;  it  represents  a 
group  of  chronic  disturbances  of  motility,  the  nature  of 
w^hich  indicates  the  site  of  the  lesion  to  be   in    the  brain. 


218   CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 

Figs.  78,  79. — Case  of  hemiplegic  type  of  cerebral  infantile  paral- 
ysis, which  has  run  its  course.  Thirteen-year-old  boy.  Contractures  of 
the  flexors  of  the  right  upper  and  lower  extremities,  with  typic  atti- 
tude and  sliglit  atrophy  of  the  whole  right  half  of  the  body.  No  reac- 
tions of  degeneration.     Mentality   slightly  defective. 


Cerebral  infantile  palsy  develops  before  birth  or  during 
the  fir^t  three  years  of  life. 

Morbid  Anatomy. — The  primary  pathologic  changes 
are  meningeal  or  cerebral  hemorrhages,  accompanied  by 
a  reactive  inflammation  of  the  adjacent  portions  of  the 
brain,  or  encephalitic  processes  and  thrombosis.  As  a 
result  we  find  destruction  of  the  section  of  the  brain 
involved,  including  softening,  fatty  degeneration,  and 
resorption,  which  lead  to  loss  of  brain  substance,  and  the 
substitution  of  the  latter  by  serous  cysts  or  l^yperostoses 
(porencephaly)  and  scar-tissue.  Aside  from  the  above 
changes  a  diffuse  sclerosis  (i.  e.,  chronic  inflammation  of 
tiie  supporting  tissue)  is  met  with ;  there  is  frequently 
a  secondary  degeneration  and  atrophy  of  the  pyramidal 
tracts. 

Etiology. — Before  Birth. — Traumatism  to  the  body  or 
brain  of  the  rnother;  congenital  syphilis,  and  premature 
birth. 

During  Birth. — Continued  asphyxiation  during  pro- 
tracted labor;  premature  discharge  of  the  liquor  amnii, 
and  compression  by  the  obstetric  forceps  (Little's  dis- 
ease). 

After  Birth. — Injuries  to  the  skull ;  acute  infectious 
di.seases,  such  as  scarlet  fever,  measles,  influenza,  and 
meningitis.  Some  cases  present  a  certain  neuropathic 
predisposition. 

Symptoms. — Two  types  are  distinguished,  the  hemi- 
plegic and  the  diplegic  (Freud). 

Hemiplegic  Type;  Spastic  Infantile  Hemiplegia ;  Acute 
Polioencephalitis  (Striimpell). — This  type  begins  suddenly, 
presenting  the  picture  of  an  acute  infectious  disease  with 
high  fever,  vomiting,  delirium,  and  convulsions.  In 
from  a  few  days  to  weeks  a  one-sided  flaccid  paralysis  of 
the  body  is  found  to  be  present,  and  it  will  be  noted  that 


Fig.  78. 


220   CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 

Fig.  80. — Congenital  spastic  rigidity  of  the  extremities  (Little's  dis- 
ease). Girl  one  and  a  half  years  old.  The  rigidity  involves  all  four  ex- 
tremities, as  well  as  the  musculature  of  the  neck  and  face.  The  legs 
show  the  characteristic  crossed  position  on  account  of  marked  involve- 
ment of  the  adductors.  The  left  arm  is  more  markedly  aftectod  than 
the  right ;  mask -like  appearance  of  the  face.     Further  course  not  known. 

the  arms,  legs,  and  face  are  involved  to  a  variable  extent. 
The  palsy  is  partial  or  complete  and  improves  in  the 
course  of  time  to  a  certain  degree.  In  some  cases  only  a 
slight  helplessness  and  a  tremor  of  one  side  are  demon- 
strable. 

Resulting  Phetiomena. — Flexor  contractures  of  the 
involved  extremities,  which  are  held  in  a  characteristic 
position  :  The  arm  is  pressed  against  the  trunk,  the  fore- 
arm is  held  semipronated  and  bent  at  right  angles  at  the 
elbows,  the  hand  is  flexed  and  curved  toward  the  ulna, 
while  the  fingers  are  flexed.  The  legs  are  slightly  bent 
at  the  knee,  the  foot  assumes  the  equinovarus  position, 
and  the  toes  undergo  dorsal  flexion.  The  involved 
members  show  athetosis  and  choreic  movements  ;  disturb- 
ances of  speech  exist,  also  aphasia  and  defective  intelli- 
gence, which  varies  in  grade  from  moral  degeneracy  to 
idiocy.  Epilepsy  develops  in  the  later  stages.  The 
muscles  are  atrophied,  but  fail  to  show  the  reactions  of 
degeneration ;  the  tendon  reflexes  are  increased. 

The  diplegic  type  includes  all  of  the  remaining  large 
variety  of  forms  of  cerebral  palsies,  especially  the  con- 
genital spastic  form  of  mu.scular  rigidity ;  the  general 
form  of  infantile  chorea  and  athetosis. 

Congenital  spastic  rigidity  of  the  muscles  (Little's  dis- 
ease) represents  a  condition  which  is  characterized  Ijy  the 
development  of  marked  stiffness  and  spastic  contractures 
of  the  legs,  with  a  peculiar  gait,  within  a  certain  time 
after  birth,  usually  at  the  time  of  mental  development. 
The  legs  are  rotated  inwardly,  strongly  adducted,  and 
often  cross  each  other;  the  feet  are  in  the  position  of 
equinovarus ;  the  upper  portion  of  the  body  is  rigid  and 
bowed  forward.  The  spasms,  which  are  due  to  increased 
excitability  of  the  reflexes,  tend  to  disappear  upon  rest 
in    bed.     In    mild    cases  they  may  only  be  elicited  by 


CONGENITAL  &PASTIC  RIGIDITY  221 


Fio.  80. 


222   CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 


FlOS.  81,  82. — Altematin};  convulsive  siiziins  of  tlir  laci.il  iniisciila- 
ture  following  porencephaly  in  a  childfour  days  old, spontaneously  born 
at  full  term.  It  presented  respiratory  dLsturbances  from  the  first  day 
on.  The  respiratory  pauses  lasted  from  one-half  to  one  minute,  were 
accompanied  by  marked  cyanosisand  a  disappearing  pulse,  and  alternated 
with  periods  of  similar  or  shorter  length  of  fleeting  respiration.  On  the 
third  day  the  whole  right  half  of  the  face  was  seized  with  tonic  spasms, 
which  lasted  several  hours.  On  the  fourth  day  similar  spasms  attacked 
the  left  half  of  the  face.  These  convulsive  seizures  continued  until  the 
sixteenth  day,  when  death  occurred.  First  one  side  and  then  the  other 
was  involved,  but  more  frequently  the  right.  The  necropsy  revealed 
(Prof.  Diirck)  a  loss  of  the  superficial  substance  (porencephaly)  in  the  re- 
gion of  the  lower  surface  of  the  pons  and  the  cerebellum,  together  with 
connective-tissue  and  mucoid  degeneration  of  the  brain  substance  in  the 
region  of  the  defect. 


rapid  passive  movements.     Reactions  of  degeneration  are 
absent.     The  muscular  rigidity  may  be  confined  to  the 


CEREBRAL  INFANTILE  PALSY 


223 


legs,  in  which  case  the  mentality  remains  intact ;  or  it 
involves  all  extremities,  converting  the  children  into 
rigid  dolls,  and  causes  cerebral  disturbances,  strabismus, 
and  defects  of  intelligence.  This  general  rigidity  is 
usually  congenital. 


Fig.  82.— See  page  222. 


General  infantile  chorea  is  distinguished  from  rheumatic 
chorea  by  its  early  appearance,  its  stationary  course,  and 
the  development  of  cerebral  manifestations. 


224   CIRCULATORY  DISTURBANCES  OF  THE  BRAIN 

Athetosis  may  be  recognized  by  the  relaxation  of  tlie 
contractures,  the  presence  of  palsy-like  signs,  and  the 
spontaneous  movements.  The  fingers  are  almost  con- 
stantly in  motion,  either  spreading  out,  flexing,  orgrasping. 

Diffuse  sclerosis  probably  possesses  its  own  morbid  anat- 
omy (diminished  size  and  dense  consistence  of  the  cere- 
bral cortex,  later,  also  of  the  white  substance ;  prolifera- 
tion of  the  glia  and  degeneration  of  the  ganglion  cells), 
but  presents  few  clinical  characteristics,  so  that  it  is 
proper  to  classify  it  with  the  infantile  palsies  (diplegic 
type). 

Disseminated  sclerosis,  with  its  circumscribed  dense 
foci  in  the  brain  and  spinal  cord,  offers  the  same  symp- 
toms as  in  adults.  The  prognosis  of  cerebral  infantile 
palsies  as  regards  recovery  is,  with  rare  exceptions,  bad, 
but  good  as  concerns  life  ;  yet  cases  have  been  recorded 
in  which  death  occurred  during  the  convulsions.  As  a 
rule  incomplete  recovery  follows  with  permanent  contract- 
ures, athetosis,  and  defective  intelligence.  The  outlook 
is  much  brighter  when  modern  orthopedic  surgery  is  re- 
sorted to. 

Diagnosis. — This  is  impossible  during  the  acute  stages 
of  the  hemiplegic  form.  Of  imjx)rtance  later  in  contra- 
distinction to  encephalitis  and  meningitis  are  the  absence 
of  fever;  in  contradistinction  to  tumors,  the  absence  of 
choked  optic  disk  and  the  initial  manifestations ;  and  in 
comparison  with  spinal  infantile  palsies,  the  hemiplegic  or 
paraplegic  and  simultaneous  spastic  form  of  the  paralysis, 
the  typic  contractures,  the  associated  movements,  the 
increased  reflexes,  the  strabismus,  and  the  defective  men- 
tality. 

Treatment. — In  the  acute  stages  depletion  and  anti- 
phlogistics  ;  later,  faradization,  massage,  dry  heat,  alcohol 
rubs,  warm  baths,  and  passive  movements.  (For  treat- 
ment of  the  contractures,  see  Poliomyelitis ;  of  defective 
mentality,  see  Idiocy.) 

TUMORS 

By  f'ir»the  commonest  tumors  are  tubercles,  solitary 
and  multiple,  which  are  chiefly  located  in  the  cerebellum 


SPINAL  INFANTILK  PARALYSIS  225 

and  pons ;  they  arc  .sharply  outlnicd,  quite  dense,  and 
vary  in  size  up  to  that  of  a  wahuit.  Other  eerebral 
growtlis  are  sarcoma,  glioma,  gumma,  i)samm()ma,  and 
those  due  to  the  cysticcrcus  and  eciiinococcus.  The 
symptomatology  and  therapy  present  no  peculiarities  char- 
acteristic of  childhood.  The  presence  of  cerebral  tul)er- 
cles  may  be  suspected  when  tuberculosis  exists  elsewhi're 
in  the  body,  and  when  chronic  meningeal  manifestations 
and  symptoms  of  cerebral  foci  arise. 

DISEASES  OF  THE  SPINAL  CORD 

SPINAL  INFANTILE  PARALYSIS 

{Acute  Anterior  PoUoviyeiilia) 

This  is  a  degenerative  paralysis  of  single  extremities, 
which  has  an  acute  onset,  runs  a  subsiding  course,  and  is 
j)robably  due  to  an  infectious  myelitic  process  in  the 
anterior  horns  of  the  cord.  The  most  frequent  subjects 
with  this  condition  are  children  from  one  and  a  half  to 
four  years. 

Morbid  Anatomy. — In  recent  cases  the  substance  of  the 
anterior  horns  is  softened  ;  microscopically  the  multipolar 
cells  are  seen  to  be  degenerated  and  the  interstitial  tissue 
inflamed.  In  older  cases  we  note  atrophy  and  sclerosis 
of  one  anterior  horn,  with  disappearance  of  all  ganglion 
cells,  secondary  degeneration  of  the  anterior  motor  roots 
and  of  the  nerves,  muscles,  and  tendons  supplied  by 
them.  [According  to  the  researches  of  Marie  and  Gold- 
scheider,  it  is  shown  that  the  anterior  horns  are  supi)lied 
by  the  anterior  branches  of  the  s])inal  arteries.  The 
areas  supplied  by  these  branches  have  been  found  necrosed 
and  softened,  the  vessels  blocked,  and  the  nerve-cells  com- 
pletely destroyed. — Ed.] 

Symptoms. — The  disease  may  be  divided  into  four 
stages  (Fischl) : 

Initial  StcKje. — It  begins  in  the  midst  of  perfect  health, 
apparently  as  an  acute  infectious  disease,  including  high 
fever,  headache,  slight  somnolence,  and,  more  rarely,  con- 


226  DISEASES  OF  THE  SPINAL  CORD 

vulsions  and  stupor.  The  duration  is  from  thirty-six  to 
forty-eight  hours. 

Stage  of  Fully  Developed  Paralysis. — The  acute  symp- 
toms disappear  and  a  flaccid  paralysis  remains,  which  in- 
volves several  extremities.  As  a  rule  the  paralysis  affects 
both  legs  and  one  arm,  an  arm  and  a  leg  on  opposite  sides, 
both  legs,  or  all  four  extremities.  The  excitability  of  the 
muscles  to  the  faradic  current  rapidly  lessens  and  the 
j)aralysis  reaches  its  highest  point  of  development.  The 
duration  of  this  stage  is  from  one  to — at  the  most — two 
weeks. 

Stage  of  Abatement  of  Paralysis. — The  paralyses  im- 
prove by  degrees,  and  the  improvement  affects  a  whole 
member  or  only  individual  muscle  groups.  The  para- 
lyzed parts  show  beginning  reactions  of  degeneration,  and 
the  diseased  muscles  react  to  the  galvanic  current  with 
sluggish  vermicular  twitchings  ;  the  An.Cl.C.  exceeds  the 
Ca.Cl.C  The  improvement  ceases  after  one,  two,  or 
more  months,  and  the  following  stage  is  reached : 

Stage  of  Completed  Paralysis  and  Sequelae. — The  ])aral- 
ysis  of  a  leg  or  an  arm  or  both  legs  now  becomes  perma- 
nent. Of  the  upper  extremities,  the  deltoid  and  shoulder 
muscles,  the  extensors  or  flexors  of  the  forearm  are  most 
frequently  involved,  while  in  the  lower  extremities  the 
extensors  and  peroneal  muscles  are  mostly  attacked. 

The  usual  sequelae  are  :  Atrophy  and  fatty  degeneration 
of  the  muscles  and  tendons  ;  sometimes  these  are  thick- 
ened because  of  increased  fatty  growth  ;  bony  growth  is 
delayed  or  bony  absorption  takes  place.  The  paralyzed 
extremities  are  wasted,  loose  at  the  joints,  the  muscles  are 
pale  and  withered,  the  tendons  are  thin  and  relax.  The 
shoulder,  when  attacked,  a])pears  flattened  and  the  finger 
can  be  introduced  between  the  acromion  and  the  humerus. 

The  skin  tem|)erature  is  subnormal  and  the  affected 
extremities  are  cyanosed.  Muscular  reaction  to  electric 
stimulation  is  lessened  or  wholly  absent.  The  tendon 
and  skin  reflexes  are  absent,  but  sensation  remains  nor- 
mal. Deformities  result  from  the  action  of  antagonistic 
muscles,  from  the  weight  of  individual  parts  and  of  the 


SPINAL  INFANTILE  PARALYSIS 


227 


Fig.  83. — Spinal  infantile  i)ar;i!y-is  in  thf  ^la-r  ..f  fully  developed 
palsy.  Tliree-ytar-old  girl.  Tin  llactid  p;iral\>i~  of  tlie  rigiit  leg  is 
shared  by  the  quadricep.s,  peroneal,  and  extensor  communis  digitorum 
muscles.  The  use  of  the  leg  was  restored  by  periosteal  tendou  trans- 
plantatiou  (F.  Lange). 


228  DISEASES  OF  THE  SPINAL  CORD 

whole  body.  These  inehule  paralytic  club-foot  and  talipes 
eqiiinus  and,  more  rarely,  talipes  calcaneus  and  club-hand. 
After  the  formation  of  these  deformities  spontaneous 
cure  is  hopeless  and  the  disease  has  reached  its  termina- 
tion. 

Prognosis. — Complete  cure  as  well  as  an  unfavorable 
ending  are  rare.  As  a  rule  the  disease  leads  to  some 
permanent  deformity.  By  means  of  timely  and  subse- 
quent treatment,  especially  by  resorting  to  modern  ortho- 
pedic methods,  it  is  possible  to  secure  functional 
improvement  and  cure.  In  the  tiiird  stage  the  condi- 
tion of  the  muscles  as  regards  electric  reactions  is  of 
prognostic  significance. 

Diagnosis. — This  cannot  be  established  in  the  acute 
stages.  Indicative  of  this  disease  are  :  The  flaccid  par- 
alysis, which  at  the  beginning  is  widely  spread,  but  later 
limited  and  stationary,  and  which,  accordingly,  runs  a 
retrogressive  course ;  the  degenerative  atrophy ;  the  loss 
of  reflexes;  the  retained  sensibility  and  sphincter  function. 
A  conclusion  as  to  what  muscles  are  paralyzed  and  to 
what  extent  they  are  affected  may  be  reached  by  deter- 
mining what  movements  are  possible  by  jialpation  of  the 
contracted  tendons  (F.  Lange). 

Treatment. — In  the  acute  stage  resort  to  an  antiphlogis- 
tic regimen,  deplete  through  the  bowels,  and  keep  at  rest 
in  bed  for. several  weeks.  If  the  paralyses  are  evident 
and  the  fever  has  disappeared,  use  electricity  over  a  long 
period  of  time,  also  massage,  passive  movements,  and 
gymnastics.  At  the  beginning  apply  a  weak  current  of 
electricity  by  passing  the  cathodal  electrode  over  the 
paralyzed  muscle,  while  the  anodal  pole  is  held  over  the 
part  of  the  spinal  cord  which  represents  the  affected  area. 
Later  employ  stronger  stimulation  by  means  of  tlie 
faradic  current  (at  first  every  other  day,  later,  daily). 
Prevent  contractures  by  the  application  of  splints,  which 
fix  and  hold  the  member  in  a  correct  jwsition.  (The 
splints  are  only  worn  at  night.)  Corrective  manipulation 
is  also  recommended  ;  periosteal  transplantation  of  ten- 
donS;  with  the  insertion  of  silk  tendons,  according  to  the 


TBANS VERSE  MYELITIS  229 

recent  simplified  operative  methods  (Lange) ;   fix    loose 
joints  by  means  of  arthrodesis. 

TRANSVERSE  MYELITIS 

Transverse  inflammation  of  the  spinal  cord  is  es|>ecially 
likely  to  follow  a  spondylitis — the  so-called  compreimon 
myelitis.  It  is  then  due.  to  the  direct  pressure  of  the 
caseous  exudate,  the  deformed  vertebrae,  to  disturbance 
of  the  circulation,  or  it  is  an  extension  of  the  inflam- 
matory process.  Aside  from  these  etiologic  factors  it 
may  also  develop  as  a  termination  of  an  acute  infectious 
disease,  or  it  may  be  caused  by  traumatism,  exposure  to 
wet,  or  syphilis. 

Morbid  Anatomy. — In  recent  cases  there  is  a  slight 
discoloration  and  softening  of  the  cord,  while  in  older 
cases  the  s})inal  cord  is  smaller  and  harder  than  normal. 
Microscopically  we  note  a  small-celled  infiltration  and 
swelling  of  the  axis  cylinders  and  of  the  connective 
tissue ;  degeneration  of  the  medullary  sheaths  and  gang- 
lion cells;  fatty  granules;  later  the  connective  tissue  and 
glia  show  proliferation  ;  ascending  and  descending  degen- 
eration of  the  spinal  tracts. 

Symptoms. — Transverse  myelitis  may  be  sudden  or 
gradual  in  onset.  Paresthesiae,  pains,  and,  later,  hyper- 
esthesife  and  anesthesise.  Spasmodic  twitchings  of  the 
extremities.  Paralysis  of  that  portion  of  the  body 
innervated  by  the  spinal  cord,  varying  according  to  the 
location  of  the  affection.  In  diseases  of  the  lumbar  cord, 
flaccid  paralysis  of  the  lower  extremities  with  atrophy, 
reactions  of  degeneration,  loss  of  reflexes,  disturbances 
of  sensation,  paralysis  of  the  rectum,  and  decubitus. 
When  the  dorsal  cord  is  involved,  spastic  paraplegia  with 
increased  reflexes,  unaccompanied  by  atrophy  and  reac- 
tions of  degeneration ;  otherwise  the  symptoms  are  the 
same.  In  involvement  of  the  cervical  cord,  jKiralysis  of 
the  arms  is  added  to  the  symptoms  of  disease  of  the 
dorsal  cord.  The  so-called  "  Brown-Sequard  paralysis," 
or  unilateral  lesions,  consisting  of  motor  palsy  and  in- 
creased   reflexes   on    the    diseased  side  and  sympathetic 


230  FUNCTIONAL  NERVOUS  DISEASES 

palsy  on  the  sound  side,  occurs  in  disease  of  one  side  of 
the  spinal  cord  (crossing  of  sensory  fibers  after  entering 
the  cord,  straight  course  of  the  motor  fibers). 

The  prognosis  is  usually  unfavorable,  excepting  in  cases 
following  syphilis  or  infectious  diseases.  The  course  is 
chronic  and  is  dependent  upon  the  causal  condition. 

Treatment. — If  due  to  spondylitis  or  syphilis,  direct 
treatment  for  those  diseases.  In  case  of  syphilis  and 
also  in  other  forms  of  myelitis  which  are  not  tuberculous, 
administer  potassium  iodid  internally  and  paint  the  site 
externally  with  iodin.  Massage  and  electricity  for  the 
muscles.  Careful  nursing  in  order  to  avoid  decubitus, 
which  is  so  frequent,  and  the  disturbances  of  the  bladder 
with  their  sequelae. 

FRIEDREICH'S  (HEREDITARY)  ATAXIA 

This  is  a  family  disease  occurring  before  puberty,  which 
is  caused  by  degeneration  of  the  posterior  columns  of  the 
cord.  It  is  characterized  by  ataxic  movements  of  the 
arms  and  legs,  nystagmus,  muscular  disturbance  of 
speech,  loss  of  knee-jerks,  extremely  chronic  and  an 
incurable  course. 

SPASTIC  SPINAL  PARALYSIS 

This  is  a  disease  of  later  childhood,  consisting  of  a 
gradually  developing  spastic  paralysis  of  the  legs  accom- 
panied by  contractures  of  the  adductors  of  the  femur  and 
of  the  muscles  of  the  calves,  crossing  of  the  legs,  pes 
equinus,  increased  reflexes  without  atrophy,  reactions  of 
degeneration  or  cerebral  manifestations.  (Little's  dis- 
ease occurs  congenitally,  or  it  arises  during  the  first 
period  of  childhood.) 

FUNCTIONAL   NERVOUS   DISEASES 

ECLAMPSIA 

{Convulsions;  Spasnis;  Eclampsia  Infantum) 

Clonic  spd'Smodie  commlslons  accompanied  by  uncon- 
sciousness.     These   represent    no    distinct    disease,    but 


ECLAMPSIA  231 

rather  a  symptom,  the  cause  of  which  is  still  unknown 
in  many  cases. 

Etiology. — Primary  Reflex  or  Functional  Eclampsia. — 
The  convulsions  arise  spontaneously  or  as  the  result  of 
sensory  disturbances  (intestinal  parasites,  foreign  bodies, 
injuries,  psychic  or  sensory  impressions).  Of  predispos- 
ing influence  is  the  physiologic  increased  tendency  to 
convulsions  in  children  (spasmophilia),  the  cause  of  which, 
according  to  Soltmann,  lies  in  the  imperfect  development 
of  the  psychomotor  inhibitory  center  together  with  in- 
creased reflex  excitability  of  the  peripheral  nerves. 
Eclampsia  may  also  precede  true  epilepsy. 

Secondary  symptomatic  eclampsia  occurs  in  diseases  of 
the  brain,  meningitis,  tumors,  hydrocephalus,  encephalitis, 
anemia,  hyperemia  (pertussis),  and  in  otitis  media.  It 
may  also  be  of  hematogenic  origin,  that  is,  the  convul- 
sions may  follow  the  presence  of  toxins  in  the  blood,  or 
the  poison  of  intestinal  bacteria,  or  they  may  be  brought 
on  by  fever,  anomalies  of  metabolism,  rachitis,  affections 
of  the  gastro-intestinal  tract,  or  overfeeding.  Convul- 
sions have  been  known  to  occur  at  the  onset  of  acute  in- 
fectious diseases  instead  of  the  initial  chill ;  on  account  of 
carbonic-acid  intoxication  in  laryngospasm  or  pneumonia ; 
in  uremia  or  when  the  blood  contains  an  insufficient 
amount  of  water.  Eclampsia  is  also  a  frequent  compli- 
cation of  tetany  and  laryngospasm,  especially  during  the 
first  eighteen  months  of  life. 

Symptoms. — The  attack  begins  suddenly,  with  pallor  of 
the  face,  a  vacant  stare,  and  rolling  of  the  eyes.  The  fol- 
lowing conditions  arise  simultaneously :  Loss  of  con- 
sciousness, tonic  rigidity  of  the  head  and  of  the  extrem- 
ities ;  flexion  of  the  fingers,  extension  of  the  legs,  and  the 
pes  equinus  or  talipes  calcaneus  position  of  the  feet. 
After  a  few  seconds  we  observe  a  clonic  twitching  around 
the  angles  of  the  mouth,  distorted  facial  expression, 
tightly  set  jaws  ;  in  older  children  gnashing  of  teeth ; 
tossing  of  the  head  to  and  fro;  riiythmic  twitching  of  the 
extremities,  as  if  electric  shocks  were  given.  Cyanosis 
around   the   mouth   and    nose,  escape  of  froth  and,  fre- 


232  FUNCTIONAL  NERVOUS  DISEASES 

quently,  bloody  saliva ;  the  pupils  are  dilated ;  the 
corneal  reflex  is  lost,  complete  failure  of  reaction  to  all 
external  stimulation ;  incontinence  of  urine  and  feces. 
The  respiration  is  shallow  and  interrupted  by  spasmodic 
j)ause8,  while  the  pulse  is  irregular  and  unequal. 

Such  an  attack  lasts  but  a  few  moments,  after  which 
the  spasms  successively  disappear,  the  face  becomes  flushed 
and  quiet,  the  child  falls  into  a  sleep,  the  beginning  of 
which  is  interrupted  by  single  twitchings.  A  single  at- 
tack is  very  rare ;  as  a  rule,  on  the  contrary,  the  convul- 
sive seizures  recur  at  longer  or  shorter  intervals  of  days, 
weeks,  or  months.  In  some  cases  a  series  of  convulsions 
occur  in  quick  succession,  even  before  the  patient 
awakens  from  a  j)revious  attack.  In  the  severest  forms 
the  patient  is  in  a  continuous  convulsive  state  for  several 
hours,  which  is  only  interrupted  by  short  periods  of 
sleep.  Exhaustion  and  venous  stasis,  on  account  of  in- 
hibition of  respiration,  may  lead  to  death.  The  intensity 
of  the  attacks  varies  from  the  severest  to  the  lightest,  in 
which  the  turning  of  the  eyes  and  the  slight  twitchings 
(as  may  also  be  seen  in  healthy  nurslings  when  aslee])) 
are  barely  noticed  by  the  jiarents.  Loss  of  consciousness 
is,  however,  constantly  present. 

Diagnosis. — Inasmuch  as  many  diseases  may  begin  with 
convulsions,  the  diagnosis  of  true  eclampsia  is  difficult  at 
the  commencement.  Careful  examination  of  all  organs 
will  prevent  errors  and  the  further  course  of  the  disease 
will  establish  the  diagnosis.  Eclampsia  is  distinguisiied 
from  organic  brain  disease  by  ])ermanent  tension  of  the 
fontanels,  whereas  in  convulsions  the  tension  is  only  dur- 
ing the  attack  ;  long  duration  (more  than  twelve  hours) 
of  the  attack,  as  well  as  prolonged  unilateral  convulsions, 
indicate  cerebral  affection.  In  favor  of  epilepsy  are : 
The  recurrence  of  attacks  over  a  long  j)eriod  of  time 
Avithout  any  apparent  cause  ;  the  presence  of  an  hereditary 
predisposition,  and  the  late  occurrence  at  the  end  of  the 
second  year  of  life. 

Prognosis. — This  should  be  guarded  and  not  made  until 
after   long   observation    of  the   child,    both   during    the 


TETANY  233 

attack  and  the  interval.  The  prospects  are  dependent 
upon  the  severity  and  frequency  of  the  attacks,  as  well 
as  the  nature  of  the  original  causal  condition.  The  reflex 
and  hematogenic  forms  of  convulsion  run,  as  a  rule,  a 
favorable  course.  Death  may  occur  during  the  attack 
because  of  asphyxiation  or  cerebral  hemorrhage.  Con- 
vulsions are  not  infrequently  followed  by  paralysis,  de- 
fective mentality,  or  true  epilepsy. 

Treatment  of  the  Attack.^Remove  clothing  ;  stimulate 
with  cold  water;  chloroform  inhalations,  chloral  enemata 
(1.0  gm.  to  30.0  cc.  milk,  starch-water,  for  two  injections) ; 
tepid  batlis  with  cold  applications  to  the  head.  In  hyper- 
emia of  the  brain  compress  the  carotids  (Seitz)  or  apply 
leeches.  After  the  attack  deplete  by  way  of  the  bowels 
(calomel)  and  skin  (stimulation  of  the  skin,  heat).  Low 
diet.  Should  the  attacks  frequently  recur,  give  the  bro- 
mids  with  or  without  chloral ;  if  rachitis  exists  adminis- 
ter phosphorus  and  resort  to  antirachitic  treatment.  [In 
those  cases  associated  with  high  fever,  antipyrin  combined 
with  bromids  sometimes  gives  excellent  results.  In  the 
cases  of  continuous  or  protracted  convulsions  small  doses 
of  mor|)hin — 5-^  to  y^^  gr. — may  be  given  hvpodermic- 
ally.— Ed.] 

TETANY 

Tetany  is  a  functional  neurosis  depending  upon  a  hyper- 
excitability  of  the  peripheral  nervous  system,  which 
chiefly  attacks  the  rachitic  children  of  poor  parents  dur- 
ing tiie  first  two  years  of  life,  especially  in  the  spring 
months. 

Etiology. — Disturbances  of  the  gastro-intestinal  tract, 
foul  atmosphere,  artificial  (cows'  milk)  feeding  (Finkel- 
stein). 

Morbid  Anatomy. — Thus  far  no  uniform  change  has 
been  noted. 

Symptoms. — A  symmetric  tonic  muscular  contraction, 
beginning  witli  the  fingers,  then  the  hands  and  toes,  and 
which  does  not  involve  the  arms  and  legs  until  after  the 
lapse  of  considerable  time;  the  musculature  of  the  trunk 
is   very   rarelv   attacked.     Characteristic  position  of  the 


234 


FUNCTIONAL  NERVOUS  DISEASES 


hands — the  fingers  are  extended  at  the  phalangeal  joints 
and  flexed  at  the  metacarpal  joints,  while  the  thumb  is 
turned  in  a  volar  direction — obstetric  hand  (Fig.  85) ;  the 
legs  are  extended  and  the  toes  flexed.     These  contractures 


Fig.  84. — Persistent  form  of  tetany  in  a  girl  a  year  and  a  half  old. 
Tetanic  contractures  of  the  arms  and  legs;  hands  in  the  "  obstetric"  po- 
sition ;  feet  in  i)lantar  flexion.  The  convulsions  lasted  three  days  unin- 
terruptedly and  disappeared  after  thorough  purging.  Trousseau's  sign, 
the  facial  phenomenon,  and  the  heightened  electric  excitability  (Ca.Cl.C. 
1.0  M.  A.  :  Ca.O.C.  3.2  M.A.)  remained  demonstrable  for  a  longtime — 
latent  form.  Etiology  :  Chronic  constipation  in  a  child  living  under  un- 
favorable conditions  of  life. 

may  continue  as  a  ])ermanent  form  of  tetany  (Escherich) 
or  they  disappear  after  a  certain  time — inta-mittent  form  ; 
the   latter   type   is   most     frequently    observed.       Dur- 


FiG.  85.— The  obstetric  hand  of  tetany.     (From  Fig.  84.) 

ing  the  interval  the  hypersensitiveness  persists  and  is 
manifested  by  the  so-called  latent  symptoms.  The.-^e  are, 
moreover,  in  some  cases  the  only  expression  of  the  di.s- 
ease — latent  tetany.     The  symptoms  of  latent  tetany  are  : 


TETANY  235 

Trousseau's  Phenomenon. — Pressure  upon  the  internal 
bicipital  groove  produces  after  a  few  minutes  the  typic 
obstetric  hand.  This  sign  when  present  is  pathognomonic, 
but  it  may  be  absent  in  some  cases. 

Erb's  Phenomenon. — Increased  excitability  of  the  motor 
nerves  to  the  galvanic  current.  Tested  by  means  of  the 
Stinzing  normal  electrode  placed  at  the  median  nerve  in 
the  elbow  and  the  indifferent  electrode  on  the  sternum. 
It  is  noted  that  the  Ca.Cl.C.  requires  less  than  0.7  mil- 
liamperes  (about  1.5  milliamp^res  normal);  the  An.O.C 
is  greater  than  the  An.Cl.C,  and,  above  all  things,  the 
weak  current  required  for  the  Ca.O.C.  (1.94  milliampdres 
in  manifest  and  2  23  milliaraperes  in  latent  tetany;  8.22 
=  normal).  This  is  a  constant  and  likewise  pathogno- 
monic symptom  (Thiemich). 

The  Chvostek,  or  Facial  Nerve,  Phenomenon. — Height- 
ened excitability  to  mechanical  stimuli.  Tapping  or  pal- 
pating the  facial  nerve  between  the  zygoma  and  the  angle 
of  the  mouth  causes  a  lightning-like  twitching  of  the 
whole  or  part  of  the  facial  musculature.  The  symptom 
is  usually  present,  but  occurs  also  in  other  neuroses. 

Laryngospasm. — Spasm  of  the  glottis  is  noted  in  many 
cases  of  tetany,  especially  in  the  latent  form.  The  first 
two  symptoms  are  called  obligate,  the  last  two,  facultative 
latent  symptoms.  Eclamptic  attacks  are  also  observed 
throughout  the  course  of  tetany. 

Course  and  Prognosis. — The  duration  is  from  three  to 
five  weeks  (Loos,  Kirchgasser).  The  prognosis  is  favor- 
able, but  serious  in  case  of  laryngospasm,  eclampsia,  and 
severe  rachitis.  Marked  improvement  of  the  tetanic  and 
laryngospastic  phenomena  follows  the  substitution  of 
cows'  milk  by  nourishment  with  infants'  foods  (Finkel- 
stein). 

Diagnosis. — In  the  absence  of  manifest  contractures  one 
of  the  "  obligate  "  symptoms  suffices  for  the  diagnosis  of 
latent  tetany.  Every  case  of  laryngospasm  should  be 
tested  for  latent  symptoms. 

Treatment. — Empty  the  intestinal  tract  ;  correct  the 
diet.     Combat  the  nervous  hyperexcitability  with  phos- 


236  FUNCTIONAL  NERVOUS  DISEASES 

phorus,  bromids,  and  chloral.  Attend  to  hygienic  condi- 
tions of  the  dwelling ;  te])id  baths.  Temporary  substitu- 
tion of  the  cows'  milk  by  feeding  with  infants'  foods. 
[This  last  statement  is  not  in  accord  with  the  most  ac- 
cepted teaching  in  regard  to  the  treatment  of  those  neu- 
roses. Fresh  cows'  milk,  properly  modified  or  diluted,  is 
considered  the  best  substitute  for  mother's  milk  and  is 
particularly  indicated  in  these  cases. — Ed.] 

PSEUDOTETANUS    (ESCHERICH) 

Pseudotetanus  presents  a  condition  similar  to  traumatic 
tetanus,  which  is  characterized  by  an  ascending  rigidity 
of  the  whole  body  and  face,  without  affecting  the  arms 
and  hands.  Trousseau's  and  Erb's  signs  are  absent ;  the 
convulsion  is  lessened  when  the  body  is  at  rest,  but  in- 
creased by  external  stimuli.  It  runs  a  favorable  course 
of  from  four  to  six  weeks. 

LARYNGOSPASM 

{Spasm  of  the  Olottis  ;  Laryngismus  Stridulus) 

Laryngospasm  is  an  apnea  occurring  in  attacks  due  to 
convulsive  seizures  of  the  glottic  muscles  and  the  other 
muscles  of  respiration.  It  frequently  runs  in  families 
and  occurs  during  the  first  years  of  life.  It  is  an  inde- 
pendent disease  as  well  as  a  nervous  phenomenon  of 
rachitis,  and  a  partial  manifestation  of  eclampsia  and 
tetany.  Laryngospasm  occurs  most  frequently  in  associ- 
ation with  these  three  affections  during  the  spring  months 
of  the  year ;  and  may  also  follow  whooping-cough,  dis- 
turbances of  digestion,  and  difficult  dentition.  As  the 
direct  cause  of  the  attack  we  note  any  mental  alteration, 
also  crying,  drinking,  exposure  to  cold,  and  catarrh.  At 
the  height  of  the  disease  attacks  occur  apparently  without 
cause. 

Symptoms. — The  laryngospastic  attack  begins  with 
sudden  cessation  of  respiration,  the  head  is  hyperextended, 
the  eyes  have  a  staring  expression,  the  patient  is  in  fear 
of  impending  death,  and  the  face  is  pale  and  cyanotic ;  to 


r.ARYNGOSPASM 


237 


Fig.  86. — Pseudotetaims.  Xinc-year-old  boy.  Tonic  spasnis  of  the 
facial  iuu.sfles;  characteri.stic  prinniiig  expression  ;  tlie  teeth  are  tightly 
pressed  upon  each  other.  Contraction  of  the  platysma  muscle.  The 
patient  shows  rigidity  of  the  whole  body,  with  the  exception  of  the 
arms,  hands,  and  eyes.  The  convulsion  disappears  largely  during  rest. 
The  ingestion  of  food  is  never  prevented.  Eecovery  in  eight  weeks. 
(E^cherich's  Clinic,  Vienna.) 

these  are  added  frequent  twitchings  of  the  face  and 
extremities  or  a  tonic  rigidity  of  the  httter.  After  the 
lapse  of  a  few  seconds  (ten  to  sixty)  breathing  is  begun  in 


238  FUNCTIONAL  NERVOUS  DISEASES 

the  form  of  short,  rapidly  repeated,  loud  and  crowing  in- 
spirations, whicli  are  followed  by  an  expiratory  movement. 
Respiration  then  sets  in,  and  with  its  return  all  other 
symptoms  disappear  and  the  child  becomes  drowsy. 
The  attacks  vary  considerably  in  number  and  in  severity. 
AVe  may  see  the  various  stages,  from  the  mildest  form,  in 
which  the  apnea  lasts  but  a  few  seconds  with  a  few  sigh- 
ing respiratory  movements,  to  the  severest  forms,  which 
terminate  fatally.  They  occur  either  every  few  days  or 
daily  and,  indeed,  as  many  as  twenty,  thirty,  or  more 
may  occur  in  one  day. 

Course  and  Prognosis. — The  disease  lasts  at  least  three 
months.  Three  stages  may  be  distinguished  (Bendix) : 
The  attacks  increase  in  intensity  and  frequency  for  three  or 
four  weeks,  then  the  symptoms  remain  stationary  for  from 
four  to  eight  weeks,  after  which  they  gradually  disappear 
for  four  more  weeks.  The  prognosis  is  likely  to  be  favor- 
able, yet  there  is  a  possibility  of  fatal  aspiiyxiation 
during  an  attack,  and  we  must  not,  therefore,  neglect  to 
watch  the  tongue  to  prevent  aspiration.  The  outlook  is 
less  favorable  in  severe  rachitis  or  when  the  disease  is 
complicated  by  j)neumonia  or  pertussis.  [Laryngitis 
occurring  during  an  attack  may  lead  to  laryngeal  stenosis 
and  necessitate  surgical  intervention.  The  prognosis  in 
these  cases  is  very  grave. — Ed,] 

Diagnosis. — The  sudden  attack  of  apnea  with  the  crow- 
ing ins})iration  is  absolutely  characteristic.  The  so-called 
apnea  of  many  children  is  not  laryngospasm,  but  an 
almost  harmless  affection. 

Treatment  of  the  Attack. — Spray  or  douche  with  cold 
water;  introduce  the  finger  into  the  mouth,  lift  the 
epiglottis,  thus  encouraging  swallowing  movements,  and 
draw  the  tongue  forward  to  prevent  the  possibility  of  its 
being  aspirated.  Slap  the  back  ;  apply  a  hot  sponge  to 
the  neck  and,  if  necessary,  artificial  respiration,  intuba- 
tion, or  tracheotomy.  When  the  attacks  follow  each 
other  in  close  succession  give  chloral  enemata  (0.5  gm.) 
and  inhalations  of  oxygen.  To  lessen  the  nervous  ex- 
citability  administer  phosphorus,  the  bromids,   infants' 


CONGENITAL  MYOTONIA  239 

foods  (Fischbein,  Finkelstein).  To  improve  the  general 
condition  institute  an  antirachitic,  general  hygienic,  and 
dietetic  regimen. 

SPASMUS  NUTANS 

During  the  months  of  primary  dentition  rhythmic 
contractions  are  noted  in  the  region  of  the  sternomastoid 
muscle  and  the  rotators  of  the  head  which  are  supplied 
by  the  brachial  plexus.  They  consist  of  an  almost  ceaseless 
rotatory  and  nodding  movement  of  the  head,  accompanied 
by  nystagmus.  The  movements  cease  when  the  head  is 
held  tightly  by  the  physician  (which  increases  the  nystag- 
mus), during  sleep,  and  darkness.  After  a  course  of 
months  the  condition  terminates  favorably. 

Etiology. — The  disease  is  undoubtedly  a  nutritional 
disorder.  Whether- due  to  a  disturbance  in  tiie  ocular 
dynamics  or  to  insufficiently  lighted  rooms  is  not  definitely 
settled. 

Treatment. — Well-lighted  dwellings  ;  phosphorus. 


SALAAM  CONVULSIONS 

These  consist  of  a  nodding  of  the  head  and  upper 
part  of  the  body,  unaccompanied  by  nystagmus,  but 
associated  with  disturbances  of  intelligence  and  epilepti- 
form seizures.     The  condition  is  frequently  fatal. 

CONGENITAL  MYOTONIA 

{Thomsen^s  Disease) 

This  is  an  hereditary  primary  parenchymatous  myop- 
athy occurring  in  families,  which  is  ciiai-acterized  by  a 
tonic  rigidity  and  contraction  of  the  voluntary  muscles 
when  voluntary  movements  are  made.  It  runs  a  pro- 
gressive, very  chronic,  and  incurable  course. 

Treatment. — Tepid  baths  and  corrective  exercises. 


240  FUNCTIONAL  NERVOUS  DISEASES 

PERIPHERAL  PARALYSES 

Facial  paralysis  is  due  to  disease  of  the  petrous  portion 
of  the  temporal  bone,  hemorrhages,  cerebral  affections, 
traumatism  during  birth,  and  exposure  to  cold.  Typic 
obstetric  paralysis  follows  any  form  of  injury  or  obstruc- 
tion at  birth.  The  palsy  may  involve  the  deltoid,  the 
infraspinatus,  the  brachialis  anticus,  or  biceps  muscles. 
A  flaccid  paralysis  of  the  arm  and  the  shoulder  is  noted, 
while  movement  of  the  hand  and  finger  is  preserved. 

Treatment. — Electricity  and  massage. 

CHOREA  MINOR 

(St.  Vitv^  Dance) 

This  is  a  psychomotor  neurosis  characterized  by  short 
involuntary  movements  of  the  different  volimtary  muscles. 
These  motions  are  similar  to  those  to  which  the  child  has 
already  been  trained  and  occur  in  children  from  two  to 
fifteen  years  of  age,  but  most  frequently  after  the  seventh 
year.  Girls  are  more  often  affected  than  boys  (70  per 
cent.). 

Etiology. — Chorea  is  an  infectious  disease  due  to  the 
injurious  effects  of  bacteria,  which  are  identical  with 
those  of  rheumatic  arthritis  and  endocarditis  and  are 
localized  in  the  psychomotor  centers  of  the  cerebral  cortex 
and  in  the  pyramidal  tracts.  The  affection,  therefore, 
corresponds  to  rheumatism  and  endocarditis,  and  may 
occur  simultaneously  with  them  or  in  the  form  of  rheu- 
matic recurrence,  or  as  the  first  manifestation  of  a  later 
rheumatic  affection  (Henry  Meyer).  Likewise  it  may 
develop  after  diseases  which  are  closely  rehited  to  rheu- 
matism, such  as  gonorrhea,  angina  lacunaris,  and  erytiiema 
nodosum.  According  to  Heubner,  chorea  is  the  "  infant- 
ile rheumatic  equivalent."  Aside  from  these  conditions 
it  may  also  follow  influenza,  scarlet  fever,  or  measles. 

Morbid  Anatomy. — The  findings  in  the  brain  are  indef- 
inite and  consist  in  arteritis  (Reichard)  and  tiie  deposition 
of  colloid  bodies  (Hudo-Vernig) ;  minute  recent  endo- 
cardial deposits  in  the  mitral  valve  with  insufficiency  of 


CHOREA  MINOR  241 

that  valvo  and  acute  nephritis.  Various  forms  of  bac- 
teria (bacilli,  streptococci,  and  staphylococci)  are  found 
in  the  blood,  in  the  brain,  in  the  endocardial  deposits,  and 
in  the  joints. 

Symptoms. — The  general  health  fails,  the  disposition  is 
altered,  and  abnormal  movements  gradually  set  in.  The 
flice  begins  to  twitch  and  there  is  involuntary  shrugging 
of  the  shoulders;  the  child  is  restless  when  sitting  and 
plays  with  the  fingers.  Later  the  arms  and  fingers  are 
in  constant  motion;  the  arms  and  shoulders  are  thrown 
about  and  the  face  is  distorted  into  all  possible  grimaces. 
Together  with  these  are  noted  various  expressions  of 
emotion  which  the  child  has  already  been  trained  to  show 
naturally,  such  as  grief,  anger,  mirth,  and  fear;  these 
movements  exhibit  somewhat  of  the  theatrical  and  are 
often  comical.  They  present  themselves  during  voluntary 
movements  of  the  hands  and  interfere  considerably  with 
them.  Likewise  there  is  a  disturbance  in  speech,  masti- 
cation, writing,  dressing,  gait,  respiration,  etc.,  and  often 
of  the  movements  of  the  heart.  The  phenomena  are 
increased  by  voluntary  actions,  in  psychic  impressions 
and  affections,  and  when  the  child  knows  it  is  being 
observed,  but  cease  almost  entirely  during  sleep.  As  the 
disease  progresses  the  appetite  is  lost,  emaciation,  pallor, 
and  irritability  increase,  and  the  ill  humor  and  the  fear- 
ful disposition  grow  worse.  In  the  severest  types  we 
note  flail-like  movements  of  the  extremities,  inability  to 
stand,  walk,  or  swallow — muscle  anarchy  (Eulenberg). 
Such  ca.ses  al.so  usually  present  psychic  dis.sociation,  con- 
fusion, and  halluciations.  St.  Vitus'  dance,  which,  as  a 
rule,  is  worse  on  one  side  at  the  beginning,  may  continue 
permanently  on  one  side  as  hemichorea. 

Paralytic  chorea  is  a  rare  form,  in  which  the  chorei- 
form movements  are  associated  with  marked  weakness  of 
the  muscles  of  the  extremities. 

Electric  chorea  consists  in  jerky  and  rhythmic  move- 
ments of  the  head  and  extremities  (usually  upper),  which 
set  in  when  the  muscles  are  comparatively  at  rest.  This 
form,  like  chorea  major  and  imitative  chorea,  which  tends 


242  FUNCTIONAL  NERVOUS  DISEASES 

to  become  rapidly  widespread  in  schools,  should  be  clas- 
sified with  hysteria. 

Course  and  Prognosis. — Chorea  lasts  from  two  to  three 
months  (forty-four  days  on  the  average,  Heubner),  but 
may  continue  for  years.  It  has  a  tendency  to  recurrence, 
which  does  not  disappear  until  puberty.  The  prognosis 
is,  on  the  whole,  favorable,  provided  it  does  not  set  in 
with  endocarditis  or  rheumatism.  The  choreic  forms  of 
psychoses  always  disappear. 

Diagnosis. — The  coordinated  and  involuntary  move- 
ments, which  cease  during  sleep,  and  the  undisturbed 
mentality  are  of  significance. 

Treatment. — Rest  in  bed  for  several  weeks  (followed 
by  sitting  up  in  bed) ;  mental  rest.  Nourishing,  but 
easily  digestible  diet.  Try  salicylic  acid ;  good  results 
follow  the  use  of  arsenic,  with  or  without  iron.  In 
severe  cases  give  the  bromids,  chloral,  or  morphin.  In 
convalescence  employ  suggestive  treatment;  rest  the 
mind ;  country  life. 

EPILEPSY 

This  consists  of  attacks  of  unconsciousness,  occurring 
at  intervals,  accompanied  by  clonic  and  tonic  convulsions 
and  followed  by  loss  of  memory.  About  60  ]>er  cent,  of 
all  cases  of  epilepsy  occur  before  the  sixteenth  year.  In 
the  earlier  years  of  childhood  they  present  largely  the 
symptoms  of  eclampsia,  from  which  they  are  distinguished 
with  difficulty.  At  this  age  the  attacks  do  not  recur 
continually  and,  indeed,  the  convulsions  of  the  nursing 
period  may  recur  after  the  lapse  of  years. 

Etiology. — Hereditary  influence,  especially  when  the 
parents  suifer  from  epilepsy  or  alcoholism  ;  injuries  to  the 
head;  increase  of  intracranial  ]>ressure  on  account  of  new 
growths,  exudates,  or  thickening  of  the  cranial  bones ; 
irritation  of  the  peripheral  nerves  by  painful  scars, 
foreign  bodies,  new  growths,  and  auto-intoxication 
(Monti) — reflex  epilepsy ;  abuse  of  alcohol  in  children  ; 
persistent  infantile  cerebral  palsies,  which  are  especially 
likely  to  cause  Jacksonian  epilepsy.     Immediate  causes 


EPILEPSY  243 

of  the  attacks  are  severe  emotions,  mental  strain,  and 
dietetic  indiscretions ;  yet  these  factors  frequently  do  not 
exist.  The  attack  is  usually  preceded  by  an  aura,  which 
may  assume  many  fr)rms  :  Headache,  hallucinations,  ring- 
int^  in  the  ears,  nodding  movements  of  the  head,  cardiac 
palpitation  ;  sensation  of  strangulation,  tremor,  pares- 
thesise,  etc.  The  aura  may  persist  in  children  as  an 
independent  affection  for  many  years. 

Symptoms. — The  attack  itself  begins  with  a  fixed  ex- 
pression of  the  face  and,  as  a  rule,  with  a  loud  cry,  and 
the  child  falls  to  the  floor  unconscious;  the  latter  is 
accompanied  by  considerable  danger  of  severe  injury. 
The  body  is  then  seized  by  a  tonic  convulsion,  in  which 
the  head  is  bent  back,  the  legs  are  extended,  the  arms 
convulsively  extended  or  flexed,  the  jaws  tightly  closed, 
and  the  thorax  set  in  the  expiratory  position.  The  face 
is  pale,  the  pupils  widely  dilated  and  do  not  react,  and 
the  eyes  are  turned  upward.  This  stage  lasts  only  a  few 
seconds  or  a  minute.  Then,  while  the  face  reddens  and 
froth  appears  at  the  mouth,  clonic  spasms  involve  the 
head,  trunk,  and  extremities.  Gnashing  of  the  teeth 
and  a  rattling  respiration  are  heard.  The  face  is  covered 
with  perspiration.  The  tongue  is  frequently  caught 
between  the  teeth  and  bitten.  Not  infrequently  there  is 
incontinence  of  feces  and  urine.  After  a  few  minutes 
the  twitciiing  ceases  and  the  child  awakens  or  falls  into 
a  long  state  of  unconsciousness.  The  attacks  return  at 
very  irregular  intervals,  sometimes  daily  and  at  other 
times  only  once  a  year. 

Abortive  attacks  occur  more  frequently  in  children 
than  in  adults,  the  so-called  epileptic  vertigo  or  petit 
mal.  These  are  characterized  by  temporary  disturbance 
of  consciousness,  with  a  fixed  expression  and  loss  of 
memory  ;  at  times  they  last  but  a  few  seconds  or  they 
are  not  noticed  at  all,' then  again  they  may  continue  for 
a  longer  period  of  time,  when  they  are  accompanied  by 
vertigo,  a  feeling  of  fear,  and  also  by  twitchings  of  the 
face.  Jacksonian  epilepsy  is  a  term  ap|)lied  to  attacks 
which  consist  only  of  clonic  spasms  of  individual  muscles 


244  FUNCTIONAL  NERVOUS  DISEASES 

or  of  a  distinct  muscle  group,  as  the  face,  arm,  or  leg  of 
one  side.  The  initial  cry  is  usually  absent  and  conscious- 
ness is  generally  preserved  at  the  beginning. 

Course  and  Prognosis. — The  course  is  always  chronic 
and  complete  recovery  is  rare.  The  patient  either 
remains  normal  mentally,  and  may  develop  to  an  extra- 
orjlinary  degree  of  intellectual  power  (Julius  Caesar, 
Napoleon),  or  in  the  course  of  time  the  character  is 
altered  and  the  child  becomes  peevish,  irritable,  and  ill 
humored.  We  may  also  observe  moral  insanity,  with 
a  tendency  to  telling  falsehoods,  adventures,  stealing, 
violent  acts ;  or  the  mind  may  gradually  decline  until 
imbecility  and  complete  idiocy  are  reached.  The  disease 
usually  continues  until  death,  and  in  many  cases  epilepsy 
is  followed  by  other  cerebral  affections.  The  prognosis 
is  the  more  favorable  the  earlier  treatment  is  begun  ;  it 
is  better  in  the  reflex  type  than  in  the  genuine  form, 
Avhich  can  be  attributed  to  no  recognizable  cause.  If 
recovery  occurs,  the  attacks  gradually  decrease  in 
frequency  and  in  intensity,  become  converted  into  ])etit 
mal,  and  finally  cease  altogether. 

Diagnosis. — Hysteric  seizures  almost  always  follow 
emotional  disturbances,  generally  during  the  day,  may 
last  for  hours,  and  are  unaccompanied  by  the  initial  cry, 
biting  of  the  tongue,  incontinence  of  feces  and  urine, 
and  are  not  followed  by  the  somnolent  state ;  nor  does 
complete  loss  of  consciousness  occur.  The  epileptic 
attack  is  very  often  independent  of  emotion,  continues 
at  the  most  for  seven  minutes,  occurs  frequently  at 
night,  and  often  leaves  traces  of  blood  on  the  pillow, 
due  to  biting  of  the  tongue.  Inquiry  into  the  anam 
nesis  and  a  careful  examination  is  important  in  every 
case. 

Treatment.  —  Vegetable  and  easily  digestible  diet ; 
large  quantities  of  milk  and  farinaceous  foods ;  prohibi- 
tion of  alcohol,  tea,  and  coffee ;  wash  with  warm  water 
and  follow  bv  cool  douches ;  tepid  baths  (25°  to  22°  R. 
[88.2°-81.5°  F.]).  Avoid  mental  strain.  The  broraid 
cure: 


NEURASTHENIA  245 

I^  Sodium  bromid, 

Potassium  bromid,  aa  1.0-2.0  gm.; 

Ammonium  bromid,  0.5  gm. — M. 

Give  this  mixture  daily  in  one  dose,  together  with  4  to 
^  pint  of  water,  followed  later  by  more  water.  If  these 
preparations  remain  ineffectual,  try  the  Flechsig  cure 
(the  results  of  which  are  indeed  uncertaiii);  for  four  or 
five  weeks  administer  0.005  gm.  of  opium  twice  daily, 
gradually  increasing  the  dose  untd  from  0.01  to  0.03 
gm.  are  given,  then  follow  immediately  by  a  course  of 
the  above  bromid  mixture  for  two  or  three  months.  A 
portion  of  the  salt  of  the  food  may  be  substituted  by 
sodium  bromid.  If  bromism  develops,  stop  the  bromids 
and  give  large  amounts  of  alkaline  waters. 

NERVOUSNESS.  NEURASTHENIA.  HYSTERIA 

Etiology  of  Nervousness. — Inherited  predisposition  to 
nervous  diseases  of  any  kind,  development  of  puberty, 
injuries,  heat  prostration,  chronic  intoxication  from 
alcohol,  coffee,  tobacco,  excessive  use  of  meat,  and  follow- 
ing acute  or  chronic  diseases ;  affections  of  the  brain  and 
spinal  cord.  Bad  example  set  by  the  parents  or  hysteria; 
strong  mental  impressions,  fright,  punishment,  religious 
impressions  ;  masturbation  ;  improper  training  ;  physical 
and  mental  fatigue  while  at  school. 

NEURASTHENIA 

Neurasthenia  represents  a  state  of  physical  and  mental 
fatigue  and  irritability. 

CMef  Symptoms.  —  Drowsiness  and  weariness  after 
slight  exertion,  poor  memory,  inability  to  concentrate 
the  thoughts,  sensitiveness  to  loud  noises  and  strong 
light ;  headache,  which  is  already  present  upon  awaken- 
ing and  increases  during  the  day,  but  improves  toward 
night.  Nervous  asthenopia  (Wilbrand, Sanger);  nervous 
dyspepsia,  with  constipation  or  diarrhea,  gastralgia, 
hyper-  or  anacidity,   with    normal   appetite;  disposition 


246  FUNCTIONAL  NERVOUS  DISEASES 

grows  worse ;  tremor  of  the  eyelids  when  the  eyes  are 
tightly  closed  (lioseubach's  sign). 

HYSTERIA 

Hysteria  is  a  condition  characterized  by  an  abnormally 
excitable  temperature  and  sensitiveness  of  the  body, 
wliich  sliows  a  j)ronounced  tendency  to  respond  to  any 
occurrence  or  event  with  decided  psychic  and  physical 
disturbances  of  varying  intensity.  Peculiar  to  hysteria 
of  childhood  is  the  occurrence  of  individual  symptoms ; 
stigmata  are  met  with.  Frequently  a  former  symptom 
of  organic  origin  persists,  that  is,  after  the  organic  condi- 
tion has  disappeared  it  remains  as  an  hysteric  symptom. 
For  example,  hysteric  contractures  after  rheumatism  or 
the  habituation  of  the  so-called  "tubards"  to  the  laryn- 
geal tube,  even  after  the  disappearance  of  the  original 
steuosis;  in  these  cases  the  respiration  is  })erfectly  free 
when  the  tube  is  not  employed  during  anesthetization. 
Characteristic  of  hysteria  is  the  fact  that  the  severest 
symptoms  disappear  in  a  short  time,  leaving  no  trace, 
and  reappear  in  another  place. 

Symptoms. — The  most  significant  of  the  manifold 
symptoms  are  :  Continual  change  of  disjiosition  from  one 
to  the  other  extreme  and  morbid  introspection;  absent- 
mindedness  ;  autosuggestibility,  as,  for  instance,  a  perma- 
nent impression  of  the  inability  to  walk,  to  lift  the  arms, 
or  to  speak  after  a  single  overexertion  of  the  muscles 
involved  ;  a  tendency  to  lie  ;  vague  pains  ;  hyperesthesife  ; 
paralyses  and  spasms  of  the  extremities,  the  voice,  speech, 
and  muscles  of  respiration,  etc. ;  such  palsies  in  contra- 
distinction to  those  following  organic  lesions  occur  un- 
systematically,  and  never  lead  to  changes  in  the  reflexes 
or  to  electric  excitability  ;  spasms  of  yawning,  laughter, 
crying,  and  shrieking.  The  affected  child  may  jimip 
about,  dance,  or  throw  itself  upon  the  floor — chm-ea 
major ;  it  may  make  grimaces — spasm  of  customary  ex- 
pressions ;  atasia  and  abasia,  that  is,  inability  to  stand  or 
walk  although  all  movements  of  the  legs  are  active  when 
the   patient  is   resting   in   bed ;  pronounced   convulsive 


HYSTERIA  247 

seizures  accompanied  by  more  or  less  disturbance  of 
consciousness  for  several  hours  or  less,  with  partial  or 
complete  preservation  of  memory  ;  catalepsy ;  outcries  at 
night;  somnambulism.  The  morning  vomiting  of  school 
children  is  also  hysteric,  especially  of  ambitious  children, 
and  is  usually  brought  on  for  the  first  time  by  emotion 
or  worry  over  lessons. 

Course  and  Prognosis  of  Neurasthenia  and  Hysteria. — 
Neurasthenia,  which  may  stretch  over  a  period  of  months 
and  years,  runs  a  variably  intermittent  course.  The  prog- 
nosis is  dependent  upon  the  severity  of  the  individual  case. 
The  course  in  hysteria  is  likewise  usually  intermittent,  and 
frequently  one  symptom  is  replaced  by  another.  The  prog- 
nosis, when  external  influence  can  be  eliminated,  is  com- 
paratively good,  especially  in  the  presence  of  single  symp- 
toms; severe  and  incurable  cases  are,  however,  met  with. 

Diagnosis. — To  avoid  error,  before  making  the  diagnosis 
of  neurasthenia  or  hysteria  a  most  careful  and  conscien- 
tious examination  of  the  body  must  be  made  and  all 
organic  diseases  excluded. 

By  the  term  mental  or  psychopathic  inferiority  (Koch) 
is  meant  a  lack  of  resistance  of  the  general  nervous 
system  of  children  who  inherit  a  neuropathic  predisposi- 
tion to  external  influences,  so  that,  on  the  one  hand, 
these  children  are  more  likely  to  be  affected  by  nervous 
disturbances ;  on  the  other,  they  do  not  possess  sufficient 
strength  to  combat  them.  Patients  of  this  class,  who 
are  often  talented,  suffer  later  from  want  of  steadiness  of 
character  and  purpose,  and  many  commit  suicide. 

Prophylaxis  and  Treatment  of  Nervousness. — Prohibit 
or  discourage  marriage  between  neuropathic  persf)ns. 
Combat  the  j^redisposition  by  the  proper  physical  and 
mental  training. 

Treatment. — Remove  from  the  hysterogenic  surround- 
ings and  avoid  anv  overexertion ;  psychic  treatment ; 
stimulate  the  child's  will  power  and,  under  certain 
circumstances,  do  not  pay  any  regard  to  the  various 
manifestations;  easily  digestible  diet  and  hydrotherapy. 
If  indicated,  give  iron,  quinin,  and  valerian. 


248  FUNCTIONAL  NERVOUS  DISEASES 


NIGHT  TERRORS 

Etiology. — Anemia,  hysteria,  alcoholism,  adenoid  vege- 
tations, punishment,  and  dreams  with  excitable  imagina- 
tions. 

Symptoms. — The  child  awakens  suddenly  from  a  peace- 
ful sleep,  showing  great  fear,  cries  out,  sits  up  in  bed, 
has  hallucinations,  fails  to  recognize  its  surroundings, 
and  appears  to  be  still  dreaming.  After  a  time  he  again 
lies  down  quietly,  falls  asleep,  and  the  next  morning 
remembers  nothing,  or  only  vaguely,  of  what  transpired 
during  the  night.  The  attacks  are  repeated  at  shorter  or 
longer  intervals. 

Treatment. — A  non-irritating  bodily  food ;  avoid  any 
mental  irritation.  Horrible  stories  must  not  be  told  and 
the  child  should  be  raised  amid  peaceful  surroundings. 
Alcohol  and  coffee  should  be  prohibited.  The  bladder 
and  rectum  are  to  be  emptied  at  the  pro])er  time.  Treat 
the  causal  condition  and  attend  to  the  hygiene  of  the 
bedroom  and  of  the  bed.  In  pronounced '  cases  give  the 
bromids. 

MASTURBATION 

Masturbation  occurs  in  every  phase  of  childhood,  even 
during  the  nursing  age. 

Etiology. — Itching  of  the  anus  in  eczema  and  oxaluria  ; 
phimosis;  balanoposthitis ;  suggestion  by  example  or 
reading.  It  is  performed  by  a  rocking  or  rubbing  move- 
ment of  the  legs  or  by  direct  manipulation.  It  results 
locally  in  enlargement  of  the  penis,  reddening  of  the 
})repuce  or  of  the  labiae,  and  is  finally  manifested  by  all 
possible  forms  of  infontile  neurasthenia. 

Treatment. — Light,  easily  digestible  vegetable  diet, 
without  alcohol,  coffee,  or  tea.  Sleep  on  a  hard  mattress. 
Emptying  of  bladder  and  rectum  at  proper  intervals. 
Care  of  the  body  and  skin.  Careful  prevention  of  all 
causes  which  give  an  opportunity,  and  institute  psychic 
treatment. 


AMAUROTIC  IDIOCY  OF  FAMILIES  249 

PSYCHOSES 

The  causes  are  the  same  as  for  nervousness.  In  case 
of  idiocy,  old  cerebral  prtKiesses  and  defects  of  the  brain 
are  also  to  be  considered.  Other  causes  are  :  Premature 
closing  of  the  fontanels  and  degeneration  of  the  thyroid 
gland,  either  hypoplasia  or  aplasia. 

IMBECILITY 

Imbecility  is  due  to  a  lack  of  development  of  the 
mind,  and  is  marked  by  the  inability  to  concentrate 
thought  and  to  realize  mental  impressicms.  It  may  be 
congenital  or  acquired  and  occurs  in  all  stages,  from 
weak  mindedness  to  fully  developed  idiocy. 

Chief  Symptoms. — The  child  learns  to  stand  and  walk 
later  than  normally ;  uncleanliness ;  delayed  and  incom- 
plete development  of  speech  ;  limited  in  the  ability  to 
grasp  and  understand  all  complicated  directions,  whereas 
the  simple  mechanics  can  be  learned ;  undeveloped  dis- 
position. Inclination  to  lie,  to  steal,  and  to  outbursts  of 
passion  and  acts  of  violence.  Slow  response  to  mental 
impressions;  shows  a  blunt  confidence  in  strangers;  active, 
early  analgesia  (Thieniich).  An  idiot  shows  a  lack  of 
intellect  from  the  very  beginning  or  he  reaches  the  intel- 
lectual height  of  a  child  from  one  to  two  years  old,  where 
a  standstill  mentally  is  reached.  Idiotic  expression ; 
babbling  speech  with  a  sobbing  tone;  uncleanliness. 
Apathetic  as  well  as  active  and  cheerful  idiots  are  met 
with.  Imbeciles  and  idiots  may  live  to  old  age,  but  in 
the  severer  types  death  occurs  much  earlier,  due  to  pneu- 
monia, eclampsia,  or  intestinal  disease. 

THE   AMAUROTIC   IDIOCY  OF  FAMILIES 

Amaurotic  idiocy  is  a  family  disease  which  appears  as 
early  as  the  first  vear  of  life,  and  is  accompanied  by  flac- 
cidity  of  the  muscles  and  disturbances  of  sight.  Ophthal- 
moscopic examination  reveals  white  specks  with  red 
centers  near  the  macula.  Death  occurs  generally  in  two 
years. 


250  PSYCHOSES 

Treatment  of  Idiocy. — Institutional  treatment,  which 
may  afford  considerable  relief  in  the  mild  cases ;  courses 
in  conversation  ;  schools  for  the  weak  minded.  In  case 
of  myxedema  and  idiocy  administer  thyroid  tablets. 

MORAL  INSANITY 

Degenerate  tendencies,  with  defect  of  the  intellect.  It 
begins  as  "  naughtiness"  and  "ill  temper."  The  child 
is  inclined  to  lie  and  is  guilty  of  cruelty,  cunning,  and 
craftiness.  He  has  a  tendency  to  commit  crimes,  such 
as  stealing  and  arson,  and  to  do  bodily  harm.  Every 
form  of  training  is  powerless. 

JUVENILE   INSANITY 

{Hebephrenia) 

This  represents  a  state  of  weakened  intellect  which 
develops  during  puberty  and  runs  a  progressive  course. 
It  begins  with  excitement,  depression,  and  hallucinations, 
and  as  it  progresses  it  enters  a  katatonic  state  (negativism, 
stereotypy,  automatism,  etc.)  and  passes  gradually,  with 
marked  mental  deterioration,  into  weak  mindedness. 

PRIMARY   PROGRESSIVE   MYOPATHY 

This  is  a  chronic  hereditary  and  family  disease  of 
certain  muscle  groups,  occurring  in  childhood  or  at 
puberty,  which  is  not  of  central,  but  of  myogenic  origin. 
It  is  accompanied  by  atrophy  and  simultaneous  hyper- 
trophy of  the  muscles,  with  intact  sensibility,  but  without 
reactions  of  degeneration  and  with  loss  of  knee-jerks. 

Morbid  Anatomy.  —  The  nervous  system  is  normal. 
Pale,  soft,  or  also  hard  muscles  ;  histologically  there  is 
proliferation  of  the  connective  tissue,  compression  of  the 
muscle-fibers,  and  eventually  degenerative  changes  and 
the  deposition  of  fat  in  the  latter. 

Symptoms. — PsemJoJiypcrh'ophic  Paralysh  (Duchenne). 
— It  begins  between  the  fifth  and  eighth  year,  generally 
in  boys,  with  uncertainty  in  gait  and  in  jumping ;  wab- 


JUVENILE  MUSCULAR  ATROPHY.  251 

bling  gait  with  protriuled  abdomen  and  lordotic  spinal 
column.  The  child  shows  characteristic  movements 
when  it  raises  itself  from  the  floor;  the  body  is  supported 
with  the  hands,  first  on  the  floor,  then  on  the  knees  and  legs, 
and  thus  climbs  slowly  up  on  its  own  body.  The  disease 
begins  always  in  the  muscles  of  the  trunk  and  the  lower 
extremities.  The  muscles,  especially  the  gluteal  and 
those  of  the  calves  of  the  legs,  are  thickened  and  shape- 
less. The  affection  progresses  slowly  and  also  involves 
the  upper  extremities,  and,  gradually  undergoing  con- 
version into  true  atrophy,  renders  the  patient  helpless. 
Death  in  the  course  of  years    from   intercurrent  diseases. 

Erb's  Form  of  Javenile  Muscular  Atrophy. — Gradually 
developing  weakness  and  emaciation  of  certain  muscle 
groups  of  the  shoulders  and  arms  without  pseudohyper- 
trophy. The  muscles  uniformly  involved  are  the  pectorals, 
trapezius,  latissimus  dorsi,  serratus  anticus,  and  the 
rhomboidei  (the  shoulder-girdle  type),  to  which  are 
added  the  gluteal  muscles,  the  quadriceps,  and  peroneal 
muscles  (pelvic-girdle  type).  Both  forms  may  coexist ; 
very  chronic  course.  Death  is  due  to  intercurrent  affec- 
tions. 

Infantile  form,  with  involvement  of  the  facial  muscula- 
ture (Duchenne,  Landouzy,  Dejerine).  This  form  begins 
in  the  muscles  of  the  face  ;  the  eyelids  are  closed  ;  whist- 
ling, laughing,  and  speaking  become  difficidt  or  impossible. 
Collapse  of  the  cheeks  and  hanging  down  of  the  lower 
lip  interfere  with  mimicking  and  form  the  typic  stupid 
"  myopathic  "  facial  expression. 

Diagnosis. — In  differentiating  the  myopathic  from  the 
spinal  muscular  atrophy,  note  in  the  former  the  juvenile 
and  family  character,  the  typic  localization  and  the  non- 
involvement  of  the  sternomastoid,  the  deltoid  muscles, 
and,  above  all,  the  small  muscles  of  the  hand.  Mu.scular 
twitchings  and  the  reactions  of  degeneration  are  absent. 

Treatment. — Avoid  overexertion;  massage  and  galvan- 
ism ;  gymnastics  and  food  rich  in  proteids. 


ACUTE   INFECTIOUS   DISEASES 

GENERAL  DISCUSSION 

The  acute  infectious  diseases  which  are  accompanied 
by  fever  are  caused  by  special  micro-organisms  which  are 
transmitted  directly  from  one  diseased  person  or  indirectly 
through  a  third  person  by  means  of  infected  articles  of 
use  or  provisions.  The  portals  of  entrance  for  the  bac- 
teria, of  which  we  are  as  yet  only  acquainted  with  a  small 
number,  are  the  mucous  membrane  of  the  respiratory  and 
digestive  tracts  and  (rarely)  the  skin.  If  the  bacteria 
find  the  condition  at  the  point  of  entrance  favorable  for 
growth,  and  if  for  any  reason  the  individual's  general 
resistance  is  weakened,  the  invading  virus  may  call  forth 
disease  symptoms,  provided  no  congenital  or  acquired 
specific  immunity  exists.  These  symptoms  depend  upon 
the  character  of  the  specific  germ,  and  are  caused  either 
by  the  bacterial  body  itself,  which  eventually  enters  the 
blood-stream  (infection  in  a  strict  sense),  or  through  their 
poisonous  metabolic  products  with  which  the  body  is 
supplied  from  the  point  of  invasion  (intoxication).  The 
disease  symptoms'are  not  noticed  so  long  as  the  micro- 
organisms are  engaged  in  combat  with  the  varying 
number  of  natural  immune  bodies  of  the  organism,  and 
so  long  as  a  sufficient  multiplication  of  bacteria  or  a 
sufficient  accumulation  of  the  specific  disease  poison  does 
not  occur. 

A  certain  period  usually  elapses  from  the  time  of  infec- 
tion until  the  disease  makes  its  appearance,  which  is 
called  the  period  of  incubation.  The  duration  of  the 
incubation  and  the  disease  symptoms  vary  according  to 
the  character  of  the  specific  germ,  each  of  which  creates 
a  symptom-complex  peculiar  to  itself ;  thus,  the  diphtheria 

252 


ACUTE  INFECTIOUS  DISEASES  253 

bacillus  causes  only  diphtheria  and  not  scarlet  fever  or 
measles.  If  a  second  disease  develops  simidtaneously 
with  or  after  another  one,  it  may  be  assumed  that  the 
causes  of  both  diseases  invaded  the  body  at  the  same 
time  or  soon  thereafter.  This  possibility  is  not  so  very 
rare,  for  between  certain  infectious  diseases  a  closer  rela- 
tionship exists  than  that  of  the  preparation  of  the  soil  by 
one  disease  for  the  other.  Such  a  relationship  exists 
between  measles  on  the  one  hand  and  influenza  and 
whooping-cough  on  the  other.  The  course  in  each  in- 
dividual form  of  acute  infection  is  typic.  In  the  acute 
exanthems  we  distinguish  between  an  eruptive,  a  florid, 
and  a  desquamative  stage,  each  of  which  (provided  com- 
j)lications  are  absent)  presents  a  fairly  definite  form  of 
development  and  duration.  In  certain  diseases  the  erup- 
tion of  the  exanthem  is  directly  preceded  by  more  or  less 
characteristic  manifestations — the  prodrmndl  symptoms. 
The  course  of  the  disease  is  dependent  upon  the  virulence 
of  the  micro-organism,  the  strength  and  the  susceptibility 
of  the  patient  to  poisons,  and,  furthermore,  upon  the 
development  of  complications,  which  may  be  traced  back 
to  the  secondary  invasion  of  non-specific  bacteria  into 
the  already  weakened  body.  Many  of  the  infectious 
diseases  are  complicated  by  nephritis,  nervous  and  psychic 
disturbances,  and  frequently  by  pronounced  anemia. 

If  death  does  not  occur,  the  disease  is  overcome  by  the 
action  of  sj)ecific  immune  bodies  which,  during  the  course 
of  the  disease,  have  developed  within  the  body  (every 
specific  poison  in  the  body  calls  forth  a  protective  measure 
to  destroy  it),  and  which  creates  a  permanent  or,  at  least, 
temporary  immunity  against  that  disease.  Much  may  be 
attained  prophylactically  by  early  isolation  of  the  |)atient 
and  personal  attention,  also  by  disinfection  of  the  articles 
used — the  secretions  and  excretions  and,  later,  of  the  sick 
room  ;  also  by  keeping  brothers  and  sisters  of  the  j)atient, 
as  well  as  convalescents,  from  visiting  school  (the  ])eriod 
of  isolation  in  measles,  rotheln,  varicella,  and  mumjis  is 
three  weeks  ;  in  diphtheria  and  typhoid  fever,  five  weeks; 
in  scarlet  fever,  six  weeks;  in  j)ertussis,  eight  weeks;  in 


254 


ACUTE  INFECTIOUS  DISEASES 


Da/  01 
diseascil. 

2. 

3. 

^. 

5. 

6. 

7. 

8. 

39° 
38° 

37° 
36* 

A 

A 

/ 

A 

/ 

V 

\a 

/ 

V 

/ 

V 

\ 

/ 

I 

\ 

> 

■ 

Exanthem. 

Initial  fever.  Eruptive  fever. 

Fig.  87. — The  type  of  fever  in  measles  (von  Striimpeli). 


Day  of 
di8«ase.  1. 

Z. 

3. 

ii. 

5. 

6. 

7. 

8. 

9. 

AT 

39* 
38* 

37' 
36° 

A 

V 

.A 

/ 

/ 

v\ 

v\ 

>  A 

V> 

\A 

/ 

I 

\ 

4 

I 

Exanthem. 
Fig.  88.— The  type  of  fever  in  scarlet  fever  (von  Strumpell). 


ACUTE  INFECTIOUS  DISEASES 


255 


i)iiy  of 
liseasaS. 

M. 

5 

6. 

7. 

8. 

9 

10 

11. 

12 

13 

1^ 

15 

16. 

17 

is 

19 

20 

21 

39* 
38' 

37* 
36* 

\ 

\a 

t 

1 

\ 

t 

A 

/ 

/ 

\ 

/ 

7 

^ 

h 

\ 

/ 

/ 

V 

/ 

\l\rA 

A 

■  ■ 

\. 

J 

ir- 

\^\/ 

Exantliern. 
Invasion  fever.       Suppuration  fever.       Desiccation  fever. 
Fig.  89. — The  type  of  fever  iu  small-pox  (Leo). 


Fastigium. 


Remission.  Termination 

by  lysis. 


Fig.  IH).— The  type  of  fever  in  the  tvphoid  fever  of  childhood  (Gerhardt- 

Seiffert). 


256  ACUTE  JNFECTIOVS  DISEASES 

PLATE  21 
Early  Symptoms  of  Measles 

Fig.  1.  Kopllk  Spots. — These  are  soon  two  days  before  tlie  eruption  of 
the  exanthein.  The  buccal  mucous  lueuibraiie  shows  reddish  specks  in 
the  region  of  the  molars,  in  which  area  are  also  seen  somewhat  elevated 
injected  spots  of  varying  .size  (fraction  of  a  millimeter)  and  of  a  rounded 
or  oval  form. 

Fig.  2.  The  Eruption  of  Measles  on  the  Mucous  Membrane  One  Day 
Before  the  Skin  Eruption.  — Irregularly  formed,  small  and  largo  pale  rod 
spots  with  serrated  edges  on  the  mucous  membrane  of  the  soft  palate, 
which  is  still  pale.  The  edges  of  the  velum  palati,  the  uvula,  and  the 
tonsils  are  reddened.  The  tougue  is  covered  with  a  thick  grayish-white 
fur. 


other  diseases  the  child  should  be  kept  home  according  to 
the  discretion  of  the  doctor).  Especial  care  must  be 
observed  to  guard  young  or  weak  children  from  infection. 
The  best  protection  is  a  hygienic  life ;  in  case  of  small- 
pox, vaccination  ;  in  diphtheria,  preventive  inoculation 
by  means  of  antitoxic  serum.  The  most  important 
measures  in  infectious  diseases  are  of  a  hygienic-dietetic 
nature  :  Provide  fresh  air,  preserve  the  body  heat  (rest  in 
bed),  careful  attention  to  the  skin  and  the  mouth  ;  a  non- 
irritating  diet,  which,  in  the  presence  of  fever,  should 
contain  no  meat.  With  respect  to  medicaments,  the.se 
are  of  less  value  than  hydrotherapeutic  measures.  Of 
specific  remedies  we  possess  the  diphtheritic  antitoxin 
and  the  antistreptococcic  serum. 

MEASLES 

{Motbilli) 

Measles  is  an  acute  febrile  di.sea.se  accompanied  by  a 
maculopapular  i*ash  and  catarrhal  phenomena. 

The  incubation  period  lasts  eleven  days  and  runs  a  symp- 
tomless course,  or  with  the  appearance  of  manifestations 
of  a  general  character. 

Ssnnptoms. — Following  the  period  of  incubation  the  dis- 
ease begins  with  catarrhal  symptoms  {catarrhal  fifaf/c),  a 
remittent  or  intermittent  fever,  catarrh  of  the  conjunc- 
tivae and  of  the  upj^er  air-pa  .'usages  (coryza,  short,  dry 
cough) ;  and  mucous-membrane  changes   of  an   exanthe- 


Tab.  2. 


MEASLES 


257 


matic  character,  consisting  of  groups  of  bluish-white 
miliary  injected  specks  (Koplik)  on  the  reddened  mucous 
membrane.  Directly  before  the  eruption  of  the  rasii 
pointed  and  star-shaped  reddening  of  the  palatine  mucous 
membrane  and  of  the  conjunctiva  is  observed  (also  of  the 
mucous  membrane  of  the  larynx  and  trachea) — the  so- 
called  enanthem. 

The  eruptive  stage  sets  in  on  the  third  day  of  the  dis- 
ease  (fourteen   days  after   infection)  with  a  high  fever 


Day  of 
disease.  1. 

2. 

3. 

^. 

5. 

6. 

7. 

8. 

39° 

38° 

37" 
36* 

h 

A 

/ 

A 

/ 

/ 

\a 

/ 

1/^ 

/ 

V 

i 

/ 

I 

S 

t 

' 

Exanthem. 
Initial  fever.  Eruptive  fever. 

Fig.  91. — The  type  of  fever  in  measles  (von  Strumpell). 

(40°  C.  [104°  F.]  and  over)  and  an  increase  in  intensity 
of  the  catarrhal  symptoms,  especially  of  the  laryngitis 
and  the  general  constitutional  sym])toms ;  in  small  chil- 
dren it  is  often  accompanied  by  convulsions.  The  erup- 
tion begins  back  of  the  ears,  spreads  to  the  face,  and  is 
accompanied  by  an  increase  in  the  fever;  it  extends  in 
from  one  and  a  half  to  two  days  to  the  neck,  trunk,  and 
extremities.  The  eruption  next  forms  little  red  })oints, 
which  rapidly  enlarge  and  develop  into  irregularly  formed 
spots  with  notched  edges  and  of  a  fairly  definite  contour; 

IT 


258  ACUTE  INFECTIOUS  DISEASES 

PLATE  22 

The  Eraption  of  Measles  Two  Days  After  its  First  Appearance.— The 

skin  of  the  whole  body,  with  the  exception  of  the  scalj),  is  covered  with 
bluish-red  luiuute  specks.  The  ellloresceut  areas  have  united  aud  formed 
large  irregularly  uotched  figures,  which  iu  the  face  and  in  isolated  patches 
on  the  body  have  been  elevated  into  papules.  On  close  inspection  we 
note — especially  on  the  large  exanthematous  areas — single  elevated  and 
reddened  follicles.  The  skin  feels  hot,  uneven,  aud  greasy,  aud  is,  ou 
the  whole,  somewhat  swollen,  especially  on  the  face.  The  eyes  and  nose 
are  swollen,  the  lids  reddened  and  glued  together,  and  the  nares  aud 
upper  lip  are  excoriated  by  the  abundant  purulent  secretion.  Tempera- 
ture, 40.1°  C.  [104.2°  F.]  ;  troublesome  cough  ;  hoarseness.  In  this  case 
the  disease  ran  a  course  of  eight  days  without  complications.  (Clinic  of 
von  Ranke,  Munich.) 


these  become  confluent  and  form  larger  area.s,  between 
which,  however,  normal  skin  is  seen  here  and  there.  On 
the  face  the  eruption  soon  assumes  the  papular  character, 
whereas  on  the  body  it  remains,  as  a  rule,  flat;  in  many 
areas  a  nodular  swelling  of  the  hair-follicles  and  of  the 
excretory  ducts  of  the  sebaceous  glands  may  be  felt.  The 
color  of  the  eruption  is  at  first  pale  red,  in  anemic  chil- 
dren it  is  paler  or  a  dirty  red,  but  it  soon  becomes  darker 
and  turns  bluish  red,  after  which  it  becomes  brownish  red 
and  fjiding,  passing  gradually  into  a  yellow  color. 

The.  whole  skin,  chiefly  of  the  face,  is  made  tense  by 
congestion  of  the  blood-vessels,  and  the  eyelids  and  the 
nose  are  particularly  swollen  ;  the  cervical  lymph-nodes 
are  enlarged.  The  urine  is  concentrated,  gives  a  positive 
diazo-reaction,  and  in  some  cases  contains  albumin.  About 
three  days  after  the  appearance  of  the  eruption  the  fever 
disappears  by  crisis  and  the  child  perspires  freely.  The 
eruption  begins  to  fade  in  the  same  order  as  in  its  devel- 
opment and  the  other  phenomena  recede,  with  the  excep- 
tion of  the  laryngitis  (or  bronchitis).  After  the  sixth 
day  a  bran-like  desquamation  takes  place,  which  is  barely 
visible.  From  then  on  recovery  .sets  in,  and  the  manifes- 
tations of  irritation  of  the  respiratory  mucous  membranes 
gradually  disappear.  Uncomplicated  cases  last  from 
eight  to  ten  days  after  the  first  day  of  eruption.  Varia- 
tions in  the  exanthem  assume  the  form  of  vesicular  or 
hemorrhagic  confluent  morbilli  (benign,  malignant). 


/;//. 


MEASLES  259 

Complications. — At  times  scarlet  fever,  varicella,  and 
diphtlieria  develop  simultaneously  with  measles.  Measles 
is  frequently  accompanied  by  severe  diseases  of  the  air- 
passages  (measly  croup,  capillary  bronchitis,  broncho- 
pneumonia), and  is  nearly  always  followed  by  inflamma- 
tion of  the  middle  ear  (Nadoleczny),  which  may  be  attrib- 
uted primarily  or  secondarily  to  the  action  of  the  poison 
of  measles.  In  the  form  of  measles  which  attacks  chil- 
dren of  poor  health  the  involvement  of  the  skin  is  of  less 
importance  than  the  process  affecting  the  mucous  mem- 
brane. If  the  virus  is  particularly  active  in  the  mucous 
membrane  of  the  bronchial  tree  we  may  meet  with 
necrotic  destruction  of  the  inflamed  pulmonary  tissue. 
In  many  cases  tuberculosis  sets  in  at  the  climax  of  the 
disease. 

Therefore  the  prognosis,  which  may  be  perfectly  favor- 
able as  regards  the  disease  itself,  is  decidedly  unfavorable 
when  complicated  by  serious  pulmonary  disease.  It  is 
bad  from  the  very  beginning  in  malignant  hemorrhagic 
morbilli,  which  is  marked  by  severe  cerebral  symptoms, 
the  early  development  of  skin  and  intestinal  hemorrhages, 
the  presence  of  gangrenous  processes  in  the  mucous  mem- 
brane [Noma  facialis  et  imlvce),  and  its  rapid  termination 
in  collapse  and  death. 

The  diagnosis  is  usually  made  without  difficulty  from 
the  characteristic  symptoms.  The  differential  diagnosis 
includes  chiefly  rubella,  scarlet  fever,  infectious  erythema, 
and  small-pox  during  the  stage  of  invasion.  In  rubella 
Koplik's  sign  and  the  diazo-reactiou  are  absent,  and  the 
accompanying  symptoms  are  of  a  mild  grade.  The  efflo- 
rescence of  the  skin  arises  in  groups,  which  show  no 
tendency  to  become  confluent ;  secondary  swelling  of  the 
skin  does  not  develop.  In  scarlet  fever  the  eruption 
begins  in  the  throat  (in  measles,  in  the  face)  and  spreads 
much  more  rapidly  and  uniformly,  and  not  by  stages,  as 
in  measles  ;  the  region  of  the  mouth  and  nose  remains 
uninvolved.  The  exanthem  consists  of  minute  points 
which  are  not  crowded  together.  Initial  vomiting  is 
almost  constant  in  scarlet  fever  (in  measles,  exceptionally) ; 


260  ACUTE  INFECTIOUS  DISEASES 

PLATE  23 

The  Eruption  of  Rubella  One-half  Day  After  its  Appearance.— In- 
numerable round,  flat,  bluish-red  papules  are  noted  on  the  face,  which 
form  into  irregular  groups  or  into  crescentic  figures;  these  do  not  coalesce, 
but  arise  in  numerous  places  on  a  common  erythematous  area.  Mild 
conjunctivitis;  the  swollen  uoSe  is  somewhat  obstructed.  No  Koplik 
spots,  yet  a  very  fine  exanthem  was  observed  on  thesoft  palate.  Isolated 
rose-red  spots  on  the  skin  of  the  trunk,  the  upper  arms,  and  the  thighs. 
The  general  health  was  undisturbed.  The  exauthem  disapi)eared  on  the 
evening  of  the  third  day.  The  patient,  Emily  Gr.,  seven  and  a  half 
years  of  age,  developed  mumps,  March  9,  1904  (see  Fig.  104) ;  returned  to 
school,  March  16,  1904;  developed  rubella,  April  4,  1904;  returned  to 
school,  April  11,  1904;  developed  whooping-cough,  April  16,  1904;  re- 
turned to  school,  June  20,  1904 ;  developed  measles,  July  1,  1904.  The 
whooping-cough,  which  at  the  time  of  the  eruption  of  measles  had  reached 
the  final  catarrhal  stage,  underwent  a  relapse,  with  fresh  paroxysms  of 
cough.    Duration  three  weeks.    Mild  cervical  adenopathy  persisted. 

angina  always  present  (in  measles,  catarrh)  and  the  fever 
disappears  by  lysis  (in  measles,  by  crisis). 

Erythema  infectiosum  (Sticker,  A.  Schmid)  is  not  in- 
frequently mistaken  for  mea.sles,  rubella,  and  scarlet  fever. 
This  is  an  infectious  epidemic  polymorphous  eruption, 
the  course  of  which  is  unaccompanied  by  constitutional 
symptoms  and  which  resembles  erythema  exudativum 
multiforme  in  form,  color,  and  development,  [t  is  dis- 
tinguished from  this  condition,  however,  by  beginning  in 
the  face,  whereas  the  extremities  are  not  attacked  until 
later  and  the  trunk  remains  free.  Erythema  infrequently 
may  be  mistaken  for  measles  by  the  simultaneous  occur- 
rence of  catarrh ;  for  scarlet  fever,  by  the  extensive  con- 
fluence of  the  dark  red  erythematous  spots.  It  is  distin- 
guished from  both  by  the  absence  of  all  associated  symp- 
toms and  the  changes  in  the  mucous  membranes,  the 
long  duration  (about  eight  days),  and  the  characteristic 
symptoms  of  involution  of  the  eruption  (see  Erythema 
Multiforme).  The  latter  peculiarity  also  serves,  together 
with  the  confluence  of  the  erythematous  spots,  to  differ- 
entiate from  rubella,  with  which  erythema  infrequently 
shares  in  common  the  absence  of  constitutional  .^iymptoms, 
and,  as  a  rule,  febrile  and  uncomplicated  course  and  ab- 
sence of  resulting  disease  processes. 

Treatment. — (General  management  as  discussed  in  the 


Tai 


/ 


RUBELLA  261 

Introduction.)  When  the  eruption  is  delayed  or  partially 
developed  resort  to  wet  or  dry  pack.  For  itching,  anoint 
with  grease.  After  the  eruption  is  completed,  daily 
baths  (35°  C.  [95°  F.]  )  and  soaping  of  the  skin.  For 
the  conjunctivitis,  boric  acid  compresses  or,  if  necessary, 
unguentum  hydrargyri  oxidi  flavus,  0.1  to  10.0  gm.  In 
troublesome  laryngitis,  infusion  of  ipecacuanha,  0.3  gm. : 
150.0,  with  aquae  laurocerasus,  1.5  cc. ;  or  extract  of 
belladonna,  0.1  gm.  to  10.0  cc. ;  aquae  laurocerasus  also 
with  codein  phosphate,  0.2  gm.,  of  which  mixture  give 
10  drops  three  times  a  day.  (For  treatment  of  pulmo- 
nary complications,  see  Diseases  of  the  Lungs.)  In 
beginning  otitis  media,  warm  applications  and  instilla- 
tions of  lukewarm  thymol-glycerin,  0.1  :  50.0  (Nado- 
leczny). 

RUBELLA 

Rubella  is  an  acute  maculopapular  exanthematous 
disease,  accompanied  by  an  ephemeral  fever  and  a  mild 
catarrh  of  the  nose.  The  period  of  incubation  is  not  as 
definite  as  in  measles,  and  lasts  up  to  three  weeks. 

Ssrmptoms. — The  early  symptoms  (Koplil^s  spots)  are 
absent.  The  exanthem,  which  appears  in  the  same  order 
and  to  the  same  extent  as  in  measles,  is  usually  milder  in 
intensity  and  consists  of  rounded  specks  about  the  size 
of  a  lentil ;  also  smaller,  and  sometimes,  though  rarely 
so,  larger,  which  occur  singly  on  the  trunk  and  the  ex- 
tremities; whereas  on  the  face  and  the  neck  they  develop 
in  groups,  forming  semicircles,  rapidly  causing  nodular 
infiltration.  The  color,  which  is  originally  dark  red, 
passes  after  a  few  hours  into  a  bluish-red,  and  after  the 
second  or  third  day  into  a  light  brownish-yellow.  The 
skin  of  the  face  is  not  swollen  as  in  measles,  but,  on 
the  contrary,  the  papules  appear  more  elevated  than  in 
measles  and  give  the  face  an  uneven  appearance.  The 
papules  do  not  become  confluent  as  in  measles,  yet  sevend 
papules  may  be  united  by  a  simultaneous  erythematous 
reddening  of  the  skin.  The  posterior  pharyngeal  wall 
appears  diffusely  hyperemic,  and  at  times  a  fineenanthem 


262  ACUTE  INFECTIOUS  DISEASES 

PLATE  24 

The  Ezanthem  of  Scaxlet  Fever  (Third  Day).— Universal  extension 
of  the  tine  puuctiform  scarlet-red  eruption,  which  is  thickest  on  the 
neck,  axilla,  on  the  back,  and  inner  side  of  the  thighs,  while  on  the  chest 
and  upper  arms  it  assumes  a  more  spotted  appearance  because  of  irregular 
distribution.  The  parts  around  the  mouth  and  nose  which  are  not  in- 
volved appear  markedly  pale  in  comparison  with  the  red,  flushed  cheeks. 
The  lips  are  dry  and  dark  red.  Skin  appeiirs  to  be  edematous  and  feels 
burning  hot  and  like  short-trimmed  plush  (due  to  follicular  swelling). 
Angina ;  swelling  of  cervical  lymph-nodes.  Temperature,  40°  C.  [104°  F.]. 
Smooth  coarse  without  complications.     (Clinic  of  von-Banke,  Munich.) 

of  the  palatal  mucosa  is  noted,  also  reddened  striae  of  the 
buccal  mucous  membrane  and  of  the  lips  (A.  Schniid). 
The  skin,  as  a  rule,  does,not  desquamate.  The  associated 
phenomena  are,  as  has  been  stated,  very  slight.  The  oc- 
cipital and  submaxillary  nodes  are  not  infrequently  pain- 
fully swollen. 

SCARLET  FEVER 

(Scarlatina) 
Scarlet  fever  is  an  acute  febrile  general  disease,  charac- 
terized by  a  scarlet-red,  fine,  punctiform  exanthem  and  a 
true  inflammatory  or  necrotic  angina.  The  stage  of  in- 
cubation is  symptomless  and  lasts  from  two  to  seven 
days.  The  disease  begins  suddenly  with  vomiting,  which 
is  soon  followed  by  chills  (in  older  children),  a  higli  fever, 
together  with  a  disproportionately  rapid  pulse,  disturb- 
ances of  swallowing,  headache,  and  at  times  convulsions 
and  delirium.  Inspection  of  the  pharynx  discloses  the 
tongue  to  be  heavily  coated  with  a  thick  white  fur,  whose 
exposed  areas  present  the  prominent  red  filiform  papillae 
(the  point  of  the  tongue  resembles  later  a  strawberry) ; 
the  mucosa  of  the  soft  palate  is  covered  with  single  dark 
red  spots ;  the  uvula  and  tonsils  are  the  site  of  a  yellow- 
ish mucoid  deposit ;  the  pharyngeal  lympliatics  are  all 
swollen,  as  are  also  the  cervical  nodes.  The  exanthem 
appears  at  the  end  of  the  first  and,  at  the  latest,  at  the 
second  day  of  the  di.^iease,  and  spreads  within  twelve  to 
twenty-four  hours  over  the  neck,  the  chest,  elbows,  por- 
tions of  the  face,  and  finally  over  the  skin  of  the  entire 
body.     It  consists  of  countless  extremely  minute  spots, 


SCARLET  FEVER 


263 


wliich  are  so  close  together  in  some  areas  that  the  skin 
appears  to  be  of  a  uniform  fiery-red  eoh)r.  The  single 
spots,  which  usually  represent  swollen  hair-follicles,  may 
be  seen,  on  close  inspection,  to  be  separated  by  areas  of 
pale  skin,  but  later  become  united  by  increasing  hyper- 
emia of  the  skin  and  sometimes  by  a  scarlet-red  erythema. 
The  slightly  edematous  skin  feels  burning  hot,  "  shotty," 
and  rough  where  the  hair-follicles  are  swollen.  It  is  note- 
worthy that  the  face  is  rarely  attacked,  but  that  iu  either 


Day  of 
diseasB.  1. 

2. 

3. 

k. 

5. 

6. 

7. 

8. 

9. 

Ar 

4    1 

\a 

^0° 
39' 
38' 

A 

V 

.A 

/ 

y 

y\ 

v\ 

k  A 

w\ 

v\ 

L 

/ 

u 

37° 

/ 

V^ 

\ 

/ 

I 

36' 

Fig.  92. 


Exanthem. 
-The  type  of  fever  in  scarlatiua  (von  Striimpell). 


case  the  parts  around  the  mouth  and  nose  remain  pale ; 
the  palms  and  the  soles  also  generally  esca])e  the  rash. 
With  the  increase  of  the  fever  from  39°  C.  [102.2°  F.l  on 
tiie  first  day  to  40°  C.  [104°  F.]  on  the  second  day, 
the  red  color  of  the  exanthem  also  increases  in  intensity, 
especially  on  the  abdomen,  the  inner  side  of  the  thighs, 
the  gluteal  regions,  and  on  the  back. 

When  the  fever  continues  high,  with  only  slight  morn- 
ing remissions,  the  eru])ti(>n  flourishes  for  from  four 
to  seven  days.  During  this  time  the  patients  are  very 
restless  (many  are  stuporous),  possess   no  appetite,  and 


264  ACUTE  INFECTIOUS  DISEASES 

PLATE  25 

Fig.  1.  Scarlatinal  Angina  (Third  Day).— Livid  discoloration  of  the 
oral  and  pharyngeal  mucosa;  the  uvula  and  tonsils  are  dark  red  ;  minute 
hemorrhages  ou  the  soft  palate  and  uvula ;  left  tonsil  covered  with  a 
whitish-yellow,  pultaceous,  and  shiny  lacunar  deposit ;  whole  right  ton- 
sil covered  with  purulent  mucus  ;  dorsum  of  tongue  still  coated  with 
thick  grayish-white  fur.  The  clean  tip  of  the  tongue  with  its  dark  red 
filiform  papillae  resembles  a  strawberry.     (Clinic  of  von  Itiuke,  Munich.) 

Fig.  2.  Lacunar  Angina.— Circumscribed  reddening  of  the  isthmus 
of  the  fauces;  tonsils  and  uvula  markedly  edematous  ;  the  latter  is  de- 
cidedly elongated.  Uvula  and  tonsils  are  covered  with  a  tenacious,  shiny 
mucus.  The  markedly  congested  tonsils  show  yellow  coalescing  lacunar 
deposits.  The  tongue  is  dry  and  coated  gray.  Cervical  lymph-nodes 
markedly  swollen.  Temperature,  3y.5°  C.  [102.4°  F.] .  Duration  of  dis- 
ease, six  days.  Ou  the  fourth  day  several  of  the  lacunar  deposits  were 
easily  removed  with  a  spoon  and  found  to  be  smooth  and  caseous,  similar 
to  collections  of  smegma. 


complain  of  great  thirst  and  pain  in  the  neck.  The 
activity  of  the  heart  is  increased.  Scanty  febrile  urine 
which  contains  a  large  amount  of  albumin.  The  bowels, 
after  a  diarrhea  at  the  beginning,  are  constipated.  The 
spleen  is  frequently  somewhat  enlarged.  Tlie  fever 
begins  to  fall  in  from  five  to  seven  days  by  lysis  and  the 
eruption  begins  to  fade.  The  stage  of  desquamation 
begins  a  few  days  later.  The  superficial  layer  of  skin  of 
the  head,  forehead,  neck,  and  back  is  shed  in  bran-lil<e 
scales,  and  in  other  areas,  especially  on  the  abdomen,  the 
hands  and  the  feet,  in  large  sections  or  lamellse.  In  some 
cases  the  skin  of  the  whole  body  undergoes  this  bran- 
like desquamation.  At  about  the  eighth  to  the  fourteenth 
day  of  the  desquamative  i)eriod  the  temperature  falls  to 
normal  and  remains  there,  provided  no  com])lications 
arise.  Simultaneously  with  the  disappearance  of  tlie 
fever  the  remaining  symptoms  disappear.  The  duration 
of  the  disease  in  favorable  ca.ses  is  from  three  to  four 
weeks.  Particular  forms  of  this  exanthem  are  miliary, 
vesicular,  variegated  (appearance  of  isolated  spots  of 
varying  size),  papular,  and  hemorrhagic  scarlatina.  The 
pharyngeal  lesion  may  also  vary  in  different  cases — it 
may  consist  of  scarlatina  with  angina  or  it  may  be  .«ear- 
latinodiphtheroid.  In  the  latter  form  the  initial  simple 
angina  may  be  converted    into   a   diphtheritic   affection 


Tab.-. 


SCARLET  FEVER  265 

with  a  strong  tendency  to  tissue  necrosis.  It  may  run  a 
violent  or  a  more  prolonged  course  and  greatly  endanger 
the  patient's  life.  In  differentiating  from  diphtheria 
note  :  The  pultaceous  (smeary)  character  of  the  deiK)sit ; 
the  marked  swelling  of  the  lymph-nodes  and  tissue 
necrosis,  which  is  rarely  so  severe  in  diphtheria ;  the 
slight  tendency  to  spread  to  the  larynx  and  trachea  and 
the  absence  of  paralysis. 

Aside  from  the  above  types  of  this  disea.se,  we  also 
meet  with  a  number  of  other  severe  forms ;  in  scarlatina 
gravissima  the  virus  has  a  rapid  paralyzing  action  upon 
the  brain  and  heart;  the  typhoidal  form  of  scarlet  fever 
is  characterized  by  a  grave  infection  accompanied  by 
typhoidal  symptoms ;  variable  hemorrhagic  and  septic 
types,  which  are  also  observed,  run  a  course  whose 
character  is  dependent  upon  that  of  the  secondary  septic 
infection. 

Complications  and  Sequelae. — The  most  frequent  compli- 
cations and  resulting  conditions  following  scarlet  fever 
include  otitis,  nephritis,  inflammatory  diseases  of  the 
lungs,  pleura,  endocardium,  and  joints.  The  scarlatinal 
nephritis  begins  usually  at  the  commencement  of  the  third 
week.  The  scanty  amount  of  urine  excreted  contains 
albumin,  casts,  and  blood.  The  general  health  is  deci- 
dedlv  disturbed.  Partial  edema,  also  anasarca  ;  hyper- 
tropiiv  and  dilatation  of  the  left  ventricle  result.  The 
affection  lasts  from  three  to  four  weeks  (usually  glomeru- 
lonephritis). In  unfavorable  cases  the  course  is  prolonged 
and  passes  into  chronic  nephritis,  or  it  progresses  rajMdly 
with  all  the  svmjitoms  of  a  severe  intoxication— uremia. 

The  prognosis  of  scarlet  fever,  because  of  the  constant 

danger  of  serious  complications,  before  the  end  of  three 

or  four  weeks  should  be  doubtful.     The  average  mortal- 

itv  rate  is  about  12  per  cent. 

'The   diagnosis,  when   the  cardinal  .symptoms  exist,  is 

easv.  .  r>    X  • 

Treatment  and  Prophylaxis  (see  Introduction).— Kest  in 
bed  for  from  throe  to  six  weeks;  fever  diet  without  meat 
for  three  weeks.     To  relieve  the  heart,  which  is  threatened 


266  ACUTE  INFECTIOUS  DISEASES 

by  the  scarlatinal  virus,  give  daily  hot  baths  (40°  C. 
[104°  F.]  )  ;  anoint  the  body  with  soap.  When  nervous 
symptoms  are  prominent  resort  to  neutral  soap-batlis 
(35°  C.  [95°  F.] ),  with  cold  rubbing  while  in  bath. 
When  pronounced  weakness  exists,  substitute  the  baths 
for  cold  washing  or  the  wet  pack. 

Special  Therapeutic  Measures. — In  case  of  delayed  erup- 
tion of  the  exanthem,  resort  to  packing.  To  lessen  itch- 
ing of  the  skin  rub  with  thymol,  0.5  gm.,  carbolic  acid, 
2.0  gm.,  and  vaselin,  50.0  gm.,  after  bathing.  In  scar- 
latinal diphtheria :  Priessnitz's  compresses,  gargle  with 
carbolic  acid  solution  (1  teaspoonful  of  5  per  cent,  car- 
bolic acid  solution  to  ^  pint  of  water) ;  cautious  swabbing 
of  the  tonsillar  deposit  with  5  per  cent,  carbolic  acid 
solution  or  tincture  of  ferric  chlorid.  Heubner  recom- 
mends injecting  a  hypodermic  syringeful  of  3  per  cent, 
carbolic  acid  solution  into  the  tonsils  and  palate  twice 
daily  (for  injection  it  is  necessary  to  attach  a  Taube  can- 
nula to  a  hypodermic  syringe),  spraying  the  oral  cavity 
every  two  hours  with  katharol  (3  per  cent  solution  of 
hydrogen  peroxid),  and  bathing  the  nose  with  salt  water 
or  boric  acid  solution.  To  lessen  the  swelling  of  the 
lymph-nodes  rub  them  with  10  per  cent  iodovasogen  or 
ichthyol-vasogen  ;  in  threatening  abscess  formation  apply 
cataplasms.  For  scarlatinal  otitis,  ice  suppositories  or  an 
ice-bag;  inject  1  to  2  drops  of  10  per  cent,  carbolic  acid 
and  glycerin ;  when  perforation  is  delayed  resort  to  para- 
centesis, followed  every  one  or  two  hours  by  injections 
of  katharol.  Treat  scarlatinal  rheumatism  by  immobil- 
izing the  joint  with  cotton  dressings  (cardboard  splints) 
and  administer  salicylates.  In  the  nephritis  of  scarlet 
fever  absolute  rest  in  bed  and  milk-diet ;  only  in  case  of 
distaste  for  the  latter,  or  long  duration  of  the  nephritis 
and  the  development  of  weakness,  is  it  permLssible  to 
cautiously  add  vegetable  .food  ;  sour  lemonade,  a  wine- 
glassful  two  or  three  times  daily.  To  stimulate  diapho- 
resis, hot  baths  followed  by  dry  packs  ;  diuretin  ;  caffein. 
Control  hematuria  by  adrenalin  or  gelatin,  internally  or 
subcutaoeously.       Prolonged  and  marked    albuminuria 


SMALL-POX.      VARIOLA  267 

indicates  a  coffeespoonful  of  infusion  of  digitalis  (0.5 
gni.:  100.0)  every  two  hours.  If  uremia  is  threatened 
resort  to  warm  baths  and  dry  pack  ;  venesection  ;  enemata 
of  chloral ;  ice-bag  to  the  head  ;  stimulants.  The  Moser 
antistreptococcic  serum  is  recommended  in  severe  cases 
as  speciiic  treatment  (not  yet  sold  on  the  market). 

SMALL-POX.     VARIOLA 

Small-pox  is  a  febrile  contagious  disease  accompanied 
by  a  pustular  eruption  and  a  course  which  is  divided  into 
several  stages. 

The  disease  begins  after  an  incubation  period  of  nine 
days  with  a  high  continuous  fever,  severe  nervous  and 
dyspeptic  manifestations,  pains  in  the  back,  weakness, 
and  occasionally  a  scarlatinal  or  a  measles-like  rash 
(initial  exanthem). 

The  eruption  appears  on  the  third  or  fourth  day  of  the 
disease,  at  first  on  the  throat  and  face,  later,  on  the  whole 
body  (it  being  thickest  on  the  face  and  hands),  as  well  as 
in  isolated  patches  upon  the  mucosa  of  the  digestive, 
respiratorv,  and  genito-urinary  tracts,  and  not  rarely  on 
the  conjunctivae.  The  virus  of  small-pox  causes  exten- 
sive vascular  changes  in  circumscribed  areas  of  the  skin 
or  mucous  membranes,  which  lead  to  hyperemia  and 
edematous  swelling,  and  later  a  marked  inflammatory 
exudation  and  infiltration  of  the  involved  parts.  At 
first  roseola-like  spots  are  seen  to  develop,  which  are 
rapidly  converted  into  flat  papules,  and  w-ithin  two  or 
three  days  after  partial  liquefaction  into  variously  formed 
vesicles ;  this  is  the  stage  of  eruption. 

Following  the  inflammatory  exudation,  further  con- 
version occurs  (from  the  end  of  the  first  week  on)  of  the 
approximately  lentil-sized  nmbilicated  vesicles — which 
are  of  mother-of-poarl  color — into  tense  pustules  on  an 
infiltrated  base,  which  are  surrounded  by  a  red  bonier, 
filled  with  a  seropurulent  fluid,  and  occasionally  tend  to 
coalesce  ;  this  is  the  stofje  of  mppuration. 

Toward  the  end  of  the  second  week  the  pustules  dry 


268 


ACVTE  INFECTIOUS  DISEASES 


up  upon  the  formation  of  new  umbilications  and  are 
gradually  altered  into  crusts,  which  generally  (from  the 
thirtieth  to  the  thirty-sixth  day — Fischl)  loosen  and  fall 
off,  leaving  behind  a  red  scar ;  this  is  the  stage  of  desic- 
caiion. 

The  fever  of  invasion  takes  a  sudden  drop  after  the 
development  of  the  vesicles.  With  the  beginning  forma- 
tion of  the  pustules  the  temperature  again  rises — suppura- 
tion/ever— which  continues  about  one  week,  Avith  evening 
exacerbations,   and   is   followed    by   a  decline  by  lysis. 


Day  of 
diseasaS. 

'i. 

5 

6. 

7. 

8 

9 

10. 

11. 

12. 

13 

1A 

15 

16. 

17 

18 

19 

20 

21 

^0° 

39" 

38' 

37* 
36* 

\ 

^ 

« 

1 

\ 

/■ 

A 

A 

y 

\ 

/ 

J\ 

^ 

^ 

\ 

/ 

/ 

V 

/ 

1/ 

\r 

A 

A 

t 

y 

J 

V 

v 

V 

Exanthera. 
Invasion  fever.        Suppuration  fever.        Desiccation  fever. 
Fig.  95. — The  type  of  fever  in  small-pox  (Leo). 

During  the  first  days  of  the  stage  of  desiccation  we 
occasionally  note  an  ephemeral  high  fever,  the  so-called 
desiccation  fever.  The  general  health  suffers  greatly  from 
the  influence  of  the  fever,  the  loss  of  sleep  on  account 
of  the  itching,  and  the  manifold  disturbances  associated 
with  the  affections  of  the  mucous  membrane.  The  urine 
contains  albumin  and  blood.  The  conjunctival  eruption 
endangers  the  eyesight,  and  the  development  of  it  in  the 
pharynx  leads  to  j)seudomen\branous  and  ])hlegmonous 
processes. 

The  symptom-complex  is  nearly  always  severe  and  in 
nursing  infjints  death  frequently  occurs,  even  at  the  time 


SMALL-POX.      VARIOLA  269 

of  the  apjjearanoe  of  the  suppuration  fever ;  in  ohler 
chiklren,  from  secondary  septic  infections  which  originate 
in  ruptured  or  scratched  pustules. 

Aside  from  the  above-described  moderate  form  of  small- 
pox, we  also  meet  with  other  severer  and  even  milder 
types.  To  the  former  belongs  the  so-called  black  small- 
pox (Purpura  variolosa),  which  is  accompanied  by  pro- 
nounced cerebral  symptoms,  marked  cardiac  depression, 
hemorrhages  into  the  skin  and  mucous  membranes,  as 
well  as  from  the  mouth,  nose,  ear,  stomach,  intestines,  and 
kidneys.  Death  sets  in  before  the  true  eruption  of  small- 
pox has  had  time  to  ap])ear. 

Another  severe  form  is  the  variola  hceniorrhagica  pud\i- 
losa,  in  which  the  hemorrhagic  diathesis  does  not  appear 
until  the  stage  of  development. 

Still  another  variety  is  the  confluent  variola,  in  which 
collapse  and  death  occur  as  early  as  the  ninth  to  eleventh 
day  from  extensive  suppuration  and  marked  general 
infection.  The  milder  forms  of  small-pox  include  variola 
sine  exanthemata,  variola  apyretica,  variola  abortiva,  and 
varioloid.  In  the  latter  variety  the  symptoms  of  the 
invasion  appear,  but  the  suppuration  fever  fails  to  develop 
(attacks  chiefly  vaccinated  individuals  in  whom  the  im- 
munity due  to  a  former  vaccination  has  worn  oflf  in  the 
course  of  years). 

The  diagnosis  before  the  appearance  of  the  vesicles  may 
cause  much  difficulty.  The  prodromal  erythema  and  the 
beginning  skin  eruption  are  distinguished  from  scarlet 
fever  and  measles  by  the  absence  of  the  enanthem,  the 
typic  scarlatinal  angina,  and  the  Koplik  spots  (the  latter 
is  also  only  present  in  measles  in  80  percent,  of  all  cases). 
As  the  disease  progresses  the  serious  nervous  symptoms 
may  also  be  mistaken  for  meningitis. 

The  prognosis  is  dependent  upon  the  character  of  the 
epidemic,  the  age  of  the  patient  (most  fatal  in  nursing 
children),  and  vaccination. 

Prophylaxis  and  Treatment. — All  j)ersons  who  have  come 
in  contact  with  a  patient  suffering  from  small-pox  should 
be    immediately   vaccinated   or   revaccinated.      Infected 


270 


ACUTE  INFECTIOUS  DISEASES 


PLATE  26 

Normally  Developed  Vaccine  Pustules  on  the  Eighth  Day  after  Vac- 
cination. 


Fig.  96.— The  first  vaccination. 


articles  slioiild  be  burned.  Strict  isolation  of  the  patient 
and  careful  nursing.  The  therapy  is  eminently  symp- 
tomatic. Lessen  the  inflammatory  process  by  the  contin- 
uous action  of  red  light  (red  window-curtains  or  panes  of 
red  glass) ;  tepid  baths  with  cold  sprays  and — as  recom- 


InO.Jt 


SMALI^POX.      VARIOLA  271 

mended  by  Hebra — the  use  of  a  water-bed,  scrupulous 
cleanliness  of  all  accessible  raucous  membranes.  Treat 
the  skin  by  painting  it  with  a  2  to  .3  per  cent,  silver  solu- 
tion or  apply  nitrate  of  silver  or  ichthyol  ointment  (6  to 
10  per  cent). 

Vaccination. — Immunity  is  obtained  against  true  small- 
pox by  inoculating  a  human  being  with  the  infectious  ma- 
terial after  its  virulence  has  been  weakened  by  passage 
through  the  body  of  a  lower  animal ;  this  is  known  as 
vaccination.  !»  Germany  vaccination  is  a  hygienic 
measure  which  is  required  by  law,  and  every  healthy 
child  between  the  ages  of  one  to  twelve  years  must  be 
vaccinated.  (The  first  vaccination  may  be  postponed  in 
children  suffering  from  febrile  and  weakening  diseases, 
anemia,  rachitis,  scrofula,  and  skin  diseases).  Animal 
glycerin-lymph  is  alone  used  as  the  inoculating  material ; 
it  is  obtainable  at  the  Central  Vaccine  Institutions  or 
from  druggists,  enclosed  in  little  capillary  tubes.  The 
first  vaccination  is  performed  on  the  right,  and  the  re- 
vaccination  on  the  left,  upper  arm.  With  a  vaccination 
lance  from  four  to  six  incisions  at  intervals  of  about  2  cm. 
[.8  in.]  are  made  over  the  deltoid  muscle,  care  being  ob- 
served to  only  incise  the  superficial  layer  of  the  skin,  so 
as  not  to  draw  blood.  [In  this  country  glycerinated 
lymph  is  furnished  in  capillary  tubes  or  on  ivory  points. 
A  vaccination  abrasion  \  inch  in  diameter  is  all  that  is 
necessary.  Care  should  be  taken  to  merely  remove  the  epi- 
dermis, not  to  cause  bleeding. — Ed.]  As  the  upper  arm 
is  grasped  and  held  tense  by  the  left  hand  of  the  phys- 
ician the  incisions  stand  open  and  the  lymph  can  be  easily 
introduced.  Normally,  the  skin  at  the  site  of  the  inocu- 
lation turns  slightly  red  in  two  days,  becomes  infiltrated 
on  the  third  ;  from  the  fifth  day  on  it  is  accompanied  by  a 
mildly  remittent  fever — up  to  20  per  cent,  of  first  vaccina- 
tions are  associated  with  albuminuria  (Falkonheim) — and 
at  times  annoying  itching;  we  observe  tlic  glossy  and 
mother-of-pearl-colored  pustules,  which  reach  their  highest 
degree  of  development  on  the  seventh  or  eighth  day.  At 
this  time  the  pustules  already  show  an  oval  central  umbil- 


272  ACUTE  INFECTIOUS  DISEASES 

ication  which  is  darkly  colored.  Occasionally  the  pustules 
are  only  surrounded  by  a  narrow  inflammatory  zone,  in 
other  cases  the  skin  of  the  whole  inoculated  area  is  red- 
dened, swollen,  and  infiltrated.  In  the  second  week  the 
pustular  contents  become  turbid,  then  purulent,  and  turn 
yellow.  The  desiccation  begins  at  the  center,  and  a 
yellowish-,  later,  blackish-brown  scab  forms,  which  falls 
off  in  about  twenty-three  days  after  vaccination.  White 
net-like  or  radial  scars  remain  behind.  Occasionally  the 
eruptive  stage  is  complicated  by  a  measles-like,  scarlatinal, 
or  a  vesicular  vaccination  rash,  or,  on  account  of  scratch- 
ing, pustules  appear  on  various  parts  of  the  body ;  gen- 
eral vaccinia  is,  comparatively  speaking,  extremely  rare. 
Worthy  of  note  is  the  possibility  of  transmission  to  an 
individual  suffering  from  some  skin  aifection  (eczema)  who 
has  not  as  yet  been  vaccinated. 

The  normal  course  may  be  considered  disturbed  if  the 
vaccine  has  become  infected  with  a  pathogenic  micro- 
organism at  the  time  of  its  manufacture  or  before  its  use, 
or  if  during  the  vaccination  the  wound  becomes  infected. 
The  most  frequent  complications  are  erysipelas  (which 
spreads  from  the  site  of  inoculation  soon  after  vaccina- 
tion) and  impetigo  contagiosa.  An  infection  of  the  pus- 
tules may  also  follow  rupture  or  scratching  of  them 
(Heubner).  To  avoid  infection,  vaccination  must  be  per- 
formed under  strict  aseptic  and  antiseptic  principles 
(cleanse  area  to  be  inoculated  with  soap  and  alcohol),  and 
the  site  of  inoculation  and  the  developing  pustules  must 
be  protected  as  much  as  possible  against  mechanical  inju- 
ries and  the  advent  of  bacteria.  Worthy  of  recommen- 
dation are  sterile  vaccine  points  which  are  enclosed  in 
glass  tubes.  A  bath  may  be  taken  after  the  vaccination 
is  manifest,  provided  the  area  is  carefully  protected  from 
wetting.  If  inflammation  becomes  excessive,  dust  with 
lycopodium  and  make  applications  of  moist  boric  acid 
compresses.  In  case  of  vaccination-erysipelas,  resort  to 
sublimate  compresses  immediately. 


VARICELLA.     CHICKEN-POX  273 

VARICELLA.     CHICKEN-POX 

Varicella  is  an  acute  febrile,  vesicular  exanthem,  which 
runs  a  mild  course. 

The  period  of  incubation,  lasting  from  two  to  two  and 
one-half  weeks,  is,  as  a  rule,  symptomless. 

The  eruption  begins  usually  on  the  face  and  head,  some- 
times also  on  the  trunk  or  the  upper  arm,  with  the 
appearance  of  small  red  nodules,  which  rapidly  increase 
to  the  size  of  a  lentil ;  the  centers  of  these  nodules  form 
small  water-colored  vesicles  after  a  few  hours.  The  ves- 
icles rapidly  enlarge  and  soon  involve  the  whole  papule, 
but  retain,  as  a  rule,  a  light  red  border.  They  contain 
but  one  chamber,  at  first  fairly  well  filled,  which,  as  it  in- 
creases in  size,  becomes  umbilicated.  The  contents  con- 
sist of  a  clear  serous  fluid  which  becomes  turbid  later,  on 
account  of  which  the  originally  gray  vesicles  assume  a 
yellow  color.  After  one  or  two  days  the  vesicular  con- 
tents dry  up  and  honey-yellow,  transparent,  thin  crusts 
are  formed,  which  later  turn  brown.  These  scabs,  when 
they  fall  off,  leave  a  red  spot  over  which  the  skin  rapidly 
grows  ;  in  extremely  rare  cases  of  exceptional  severity 
white  contracted  scars  are  left  behind. 

The  nu!iiber  of  vesicles  is  very  variable,  as  a  rule,  only 
a  few  dozen.  They  are  found  on  all  parts  of  the  body, 
but  are  thickest  on  the  back,  breast,  and  the  scalp.  Ves- 
icles also  develop  in  about  one-third  of  the  cases  upon  the 
conjunctival,  oral,  and  pharyngeal  mucous  membranes; 
more  rarely  upon  the  genital  mucosa.  They  soon  lose 
their  covering  and  are  more  likely  to  resemble  aph- 
thous ulcers.  The  eruptions  of  varicella  never  arise  at 
one  time,  nor  are  all  ever  converted  into  vesicles.  They 
occur  more  often  individually  within  the  course  of  sev- 
eral days,  being  separated  by  intervals  of  time  ;  and  it 
will  be  observed  that  one  portion  is  papular  in  form  and 
undergoes  resolution  without  entering  the  vesicular  stage. 
Thus  we  may  note  the  various  stages  in  development  of 
the  eruption  side  by  side  at  the  same  time  ;  small  red 
papides  with  or  without  miliary  vesicles;  also  vesicles  of 

18 


274  ACUTE  INFECTIom  DISEASES 

PLATE  27 

The  Eruption  of  VariceUa  on  the  Fourth  Day.— The  second  crop  of 
the  eruptiou  consists  of  a  few  dozen  vesicles,  some  of  which  are  in  process 
of  development,  while  others  are  already  beginning  to  suppurate.  Of 
the  first  eruption  nothing  remains  but  little  brownish  scales  and  red 
spots.  Mucous  membranes  not  involved.  (On  the  first  day  a  number 
of  pin-head-sized,  grayish-yellow  vesicles,  surrounded  by  a  red  zone, 
appeared  on  the  anemic  palate.)  Afebrile  course.  General  health  good  ; 
excessive  itching.  No  albuminuria.  Duration  of  disease  was  eight 
days. 


varying  size  on  an  infiltrated  or  slightly  altered  base  con- 
taining light  or  turbid  contents ;  finally,  the  various 
grades  of  desiccation  and  the  remaining  red  areas  of  the 
skin. 

The  duration  of  the  disease  varies  from  five  to  ten 
days,  depending  upon  the  number  of  relapses,  while  full 
restoration  of  the  skin  occurs  in  about  three  weeks. 
During  the  first  few  days  and  at  the  appearance  of  each 
new  crop  of  vesicles  a  high  fever  develops.  The  general 
health  is  otherwise  disturbed  only  by  the  itching  of  the 
skin.  The  scratching  which  is  indulged  in  may  lead  to 
secondary  infection,  suppuration  of  the  vesicular  contents, 
or  to  the  .subsequent  formation  of  furuncles  and  deep- 
seated  skin  ulcers. 

Variations  in  the  eruption  are  designated  as  varicella 
conJluenSy  bullosa  vel  hcemorrhagica.  A  mild  form  of 
nephritis  develops  in  rare  cases. 

The  differential  diagnosis  consists  in  distinguishing 
varicella  from  lichen  urticatus  and  true  small-pox.  The 
eruption  of  liclien  urticatus  selects  by  preference  the 
lower  half  of  the  body,  feels  very  dense,  and  never 
undergoes  a  vesicular  change.  Of  significance  in  true 
small-pox  are  the  severe  prodromata,  high  fever,  erysipe- 
latous swelling  and  reddening  of  the  face  and  scalp, 
ext^nsiv^e  coalescence  of  the  vesicles  and  pustules,  and 
the  absence  of  the  various  stages  of  development  of  the 
eruption  at  one  time,  which  is  so  characteristic  of  chicken- 
pox  (Heubner). 

Treatment. — Rest  in  bed  for  several  days;  non-irritat- 
ing diet  (nephriti.s).     Protect  against  secondary  infection 


j^^ 


DIPHTHERIA  275 

(in  case  of  excessive  itching  use  thymol  ointment  or  dust 
with  talcum  powder  or  cornstarch). 

DIPHTHERIA 

Dii)htheria  is  an  acute  infectious  disease  characterized 
by  the  formation  of  membranous  deposits  and  toxic 
constitutional  symptoms. 

The  cause  of  diphtheria,  the  Klebs-Loffler  bacilhis,  is 
deposited  on  the  mucous  membrane,  preferably  of  the 
tonsils,  of  the  nose,  or  of  the  larynx  and  trachea.  In 
these  regions  it  multiplies  rapidly  and  after  a  variable 
period  of  incubation  causes  necrosis  of  the  epithelium 
and  marked  alterations  in  the  blood-vessels  of  the  mucous 
membranes.  These  vessels  are  congested  and  at  high 
tension  and  permit  the  blood-serum  to  leak  out  rapidly 
and  in  large  quantities  {fhrinoits  exudate). 

Coagulation  of  the  exudate  causes  the  formation  of  the 
fibrinous  diphtheritic  pseudomembrane  (see  Plate  10, 
Fig.  1).  The  latter  is  sometimes  loosely  attached  to 
the  mucous  membrane  which  has  been  deprived  of  its 
epithelium  (croupous),  but  at  other  times  it  is  adherent 
and  extends  deeply  into  the  mucosa  {diphihentic).  The 
diphtheria  bacillus  requires  much  oxygen  and  therefore 
spreads,  as  a  rule,  only  on  the  surface  of  the  mucous 
membranes,  especially  of  the  respiratory  tract,  and  but 
rarely  extends  to  the  deeper  tissues,  as  into  the  circula- 
tion and  the  internal  organs.  From  this  local  focus  the 
whole  organism  is  supplied  with  the  poisonous  metabolic 
products,  the  diphtheria  toxin.  The  latter  rapidly  enters 
the  circulation  and  travels  to  the  viscera,  where,  attack- 
ing the  living  cells,  it  causes  the  development  of  degen- 
erative manifestations,  esj)ecially  of  the  heart  muscles 
(fatty,  and  at  times,  waxy  degeneration  or  secondary 
interstitial  processes),  the  kidneys  (parenchymatous 
nephritis),  and  the  peripheral  nerves  (peripheral  neuritis 
with  inflammatory  changes  in  the  spinal  cord). 

The  activity  of  the  bacillus  of  diphtheria  may  be 
influenced  to  a  certain  extent  by  a  mixed  infection  with 
other  pathogenic  bacteria,  especially  the  streptococcus. 


276  ACUTE  lyFECTIOUS  DISEASES 

PLATE  28 

Fig.  1.  Diphtheria  of  the  Lips  following  Measles  in  a  Child  Two 
and  a  half  Years  Old. — Tlie  upper  aud  lower  lips  are  greatly  swollen  and 
covered  by  thick  yreenish-yellow  deposits  (joined  at  the  cuds),  which 
have  spread  inward  to  the  oral  mucosa.  The  pseudonicmbraue  is  firmly 
adherent  aud  cannot  be  drawn  off  without  causing  hemorrhage  and  the 
loss  of  tissue  (microscopic  examination  showed  the  presence  of  large 
numbers  of  the  dijjhtheria  bacillus).  Fetor  of  the  breath.  The  fauces 
are  dark  red,  but  free  of  deposit.  The  dejwsit  disappeared  in  six  days 
after  local  and  specific  treatment.     (Clinic  of  von  Eanke,  Munich. ) 

Fig.  2.  Diphtheria  of  the  Pharjmz  One  Day  After  Senun  Injection. 
—Uvula,  tonsils,  and  posterior  pharyngeal  wall  are  reddened  ;  the  median 
surfacesof  the  palatine  tonsils  present  symmetric,  whitish-yellow,  sharply 
outlined  fibrinous  deposits,  which  are  surrounded  by  a  fairly  broad 
blood-red  zone  (demarcation  of  serum  action).  Two  days  later  the 
deposits  had  undergone  softening,  became  smaller  and  smaller,  and 
finally  disappeared.     The  fever  disappeared  in  three  days. 


The  sjrmptom-complex  is  very  variable  and  depends 
upon  :  The  localization  of  tlio  primary  disease  focus  ;  the 
reaction  of  the  mucous  membrane  to  the  invasion  of  the 
bacilli ;  the  quantity  and  quality  of  the  bacterial  poi.son 
on  the  one  hand,  the  susceptibility  of  the  individual  to 
the  poison  on  the  other.  The  mucous  membrane  reacts 
in  one  case  only  with  catarrhal  manifestations,  in  another 
case  with  the  formation  of  fibrinous  exudates  and 
necrosis.  The  organism  reacts  with  a  high  ephemeral 
fever  and  mild  albuminuria  and  at  other  times  with  grave 
phenomena  :  High  fever,  marked  albuminuria,  di-sease  of 
the  cardiac  muscle,  and  paralysis. 

The  local  and  general  symptoms  need  not  necessarily 
correspond  to  each  other  in  severity,  for  insignificant 
pathologic  changes  in  the  mucous  membranes  may  be 
accompanied  by  the  gravest  manifestations  of  intoxication 
and  the  reverse  (Esehcrich). 

The  beginning  and  course  of  the  diphtheria  may  be 
fulminant  or  insidious,  and  at  one  time  the  local,  at  an- 
other the  general,  .symptoms  i)redominate.  (A  character- 
istic type  of  fever  does  not  exist.)  There  is  constant 
danger  of  the  local  process  extending  to  the  deeper  air- 
passages  with  the  sudden  appearance  of  toxic  symptoms. 
The  duration  of  the  disease  is  fairly  indefinite,  depend- 


7>'/- 


/></./. 


DIPHTHERIA  277 

ing  upon  the  severity  of  the  case  and  the  onset  of  com- 
plications. 

According  to  the  localization  of  the  pro<'-ess  we  distin- 
guish between  pharyngeal,  nasal,  laryngeal,  conjunctival, 
vulvar,  and  wound  diphtheria. 

The  most  common  is  the  pharyngeal  diphtheria.  The 
mucous  membrane  of  the  pharynx  is  reddened  and  swol- 
len and  the  tonsils  and  uvula  are  considerably  eularged. 
The  tongue  is  heavily  coated  and  the  odor  of  the  breath 
is  fetid.  Several  small  Avhite  fibrinous  plaques  are  seen 
on  one  tonsil,  more  rarely  on  the  uvula  or  posterior 
pharyngeal  wall,  which  rapidly  coalesce  into  an  irregular 
continuous  deposit.  The  latter  may  remain  stationary 
or  spread  by  contiguity  or  by  bounds  to  symmetric  parts 
of  the  opposite  side.  In  the  progressive  form  the  isthmus 
of  the  fauces  and,  later,  the  posterior  wall  of  the  pharynx 
are  soon  covered  with  a  thick  layer  of  fibrinous  exudate, 
and  by  ascending  and  descending  processes  the  mucous 
membrane  of  the  mouth,  of  the  pharyngeal  cavity,  and 
of  the  larynx  and  trachea  are  also  attacked.  The  deposit, 
which  is  originally  white,  soon  becomes  yellowish  or 
yellowish  gray  in  color ;  it  is  sharply  outlined,  elevated, 
tenaciously  elastic,  and  may  be  fairly  easily  removed 
from  the  reddened  infiltrated  mucous  membrane  in  large 
sections,  accompanied  by  the  loss  of  blood  and  tissue  sub- 
stance. 

The  lymph-nodes  are  always  infiltrated  and  hard.  In 
severe  cases  the  lips  and  nares  are  excoriated  by  a  sero- 
sanguinolent  secretion  ;  the  speech,  because  of  the  im- 
mobilization of  the  velum  palati,  is  nasal  and  the  respira- 
tion is  rasping  and  snorting.  The  toxic  manifestations 
are  variable  in  nature  ;  when  the  process  is  very  extensive 
they  are  usually  quite  pronounced,  and  consist  of  high 
fever,  considerable  albuminuria,  and  swelling  of  the 
spleen  and  liver ;  paralyses  develop  during  the  convales- 
cence. 

Aside  from  these  typic  forms  of  diphtheria,  we  also 
observe  especiallv  mild  and  particularly  severe  varieties. 
The  mild   type   of  diphtheria  consists  only  of  a  severe 


278  ACUTE  INFECTIOUS  DISEASES 

PLATE  29 

Diphtheria  Gravis  (Gangrenous,  "  Septic  "  Diphtheria).— "  The  ton- 
sils on  both  sides  are  swollen  to  the  circumference  of  a  hazel-nut,  their 
surfaces  are  irregularly  fissured,  have  a  foul  odor,  and  a  dirty,  yellowish- 
brown  color.  On  incision  the  parenchyma  of  the  tonsils  is  found  to  have 
become  gangrenous.  The  surrounding  mucous  membrane  is  decidedly 
reddened  and  swollen,  the  uvula  is  considerably  thickened  and  glossy. 
The  surface  of  the  tongue  has  a  dirty  brown  color.  The  larynx  is  not 
involved."     (From  von  Bollinger,  Atlas  of  Pathologic  Anatomy.) 


and  obstinate  inflammatory  catarrh  of  the  pharyngeal 
mucous  membrane ;  as  regards  the  presence  of  membran- 
ous deposits,  these  are  confined  to  single  disseminated, 
mostly  lacunar  depo.sits  (angina  diphtheritica,  diphtheria 
punctata).  The  toxic  symptoms  are  likewise  mostly 
mild,  but  may  exceptionally  be  severe  and  lead  to  death 
before  typic  local  changes  are  noticeable  (hypertoxic 
form). 

Diphtheria  gravis  (Heubner),  formerly  called  "septic 
diphtheria,"  consists  of  extensive  mucous-membrane  in- 
volvement, accompanied  by  putrefactive  processes  and 
the  gravest  manifestations  of  intoxication.  It  is  caused 
by  extraordinary  virulence  of  the  micro-organism  or  by 
a  high  degree  of  individual  susceptibility  to  the  virus. 
The  patients  usually  die  soon  from  the  double  action  of 
absorbed  bacterial  virus  and  the  products  of  putrefaction 
or  from  pneumonia  or  pyemia. 

Laryngeal  Diphtheria  (Croup). — This  condition  is  usually 
an  accompaniment  to  or  a  result  of  pharyngeal  diphtheria  ; 
the  latter  has  a  marked  influence  upon  tlie  disease  pic- 
ture. With  the  primary  localization  in  the  lar\'nx  we 
note  at  first  the  symptoms  of  a  laryngotracheitis,  which, 
however,  grows  steadily  worse  ;  hoarse  and  finally  toneless 
voice;  a  dry,  irritating  cough;  difficulty  in  breathing. 
In  beginning  stenosis  (inflammatory  swelling — diphther- 
itic deposit)  the  auxiliary  muscles  of  respiration  become 
active  and  an  inspiratory  retraction  of  all  yielding  parts 
of  the  thorax  occurs.  Inspiration  and  expiration  become 
slower,  labored,  and  accompanied  by  crackling  rules, 
especially  on  inspiration.  Occasionally  attacks  of  as- 
phyxiation follow  the  collection  of  mucus  and  obstruction 


lab.2S 


I- 


DIPHTHERIA  279 

by  loosened  sections  of  membrane.  If  a  severe  form  of 
increasing  stenosis  is  not  checked  by  an  operation  the 
process  may  even  spread  to  the  bronchial  tubes,  and  the 
patients  die  from  the  double  action  of  carbonic  acid  and 
diphtheritic  intoxication. 

Nasal  Diphtheria. — This  also  is  generally  an  accompani- 
ment of  pharyngeal  diphtheria.  In  nursing  infants  the 
nose  is  often  the  primary  seat  of  the  diphtheria,  and  in 
this  case  there  is  a  constant  tendency  to  septic  complica- 
tions. Wc  note  the  following  symptoms :  Swelling  of 
the  nose,  obstructed,  noisy  nasal  breathing,  serosanguino- 
lent,  flaky,  and  (later)  purulent  discharge. 

llhinoscopic  Picture. — Reddening  and  swelling  of  the 
mucosa  ;  white  fibrinous  deposits,  which  are  mostly  con- 
fined to  the  posterior  portions  of  the  nose.  Toxic  symp- 
toms also  arise,  as  in  other  forms  of  diphtheria.  A 
febrile  purulent  coryza  is  suggestive  of  diphtheria.  The 
term  '*  rhinitis  (pseudo)membranacea  "  is  employed  to  des- 
ignate a  benign  form  of  nasal  diphtheria  with  extensive 
membrane  formation,  but  without  disturbance  of  the  gen- 
eral health. 

Diphtheritic  Conjunctivitis. — Diphtheria  attacks  the 
conjunctiva)  rather  rarely  as  a  primary  or  a  secondary 
condition.  It  arises  gradually  either  in  the  croupous  or 
the  diphtheritic  form  (from  an  anatomic  point  of  view), 
that  is,  deposits  are  formed  which  are  easily  pulled  off,  or 
a  pseudomembrane,  varying  in  color  from  bluish  white  to 
that  of  amber,  develops  on  the  conjunctiva,  which  can  be 
loosened  only  at  the  expense  of  hemorrhage  and  loss  of 
substance.  The  diphtheritic  form  may  also  involve  the 
bulb  and  not  rarely  tiie  cornea  also.  The  serosanguino- 
lent  secretion  is  converted  into  a  blennorrhea  during  the 
healing  stage.  Toxic  symptoms  and  resulting  conditions 
may  occur,  as  in  any  other  form  of  diphtheria. 

Diphtheria  of  the  Vulva. — This  is  a  rare  localization  of 
diphtheria  wliich  is  associated  with  marked  manifesta- 
tions of  a  severe  intoxication.  The  mons  veneris,  the 
inner  surface  of  the  thighs,  and  the  labiie  majores  are 
considerably  swollen  antl  reddened  and  the  neighboring 


280  ACUTE  LSFEt'TloUS  DlHEAHEii 

PLATE  30 

Fig.  1.  Diphtheria  of  the  Conjunctiva  In  a  Young  Boy.— "  Tlie  in- 
flammatory swelling  ami  reddening  of  tlie  upper  lid  is  more  pronouuccd 
than  in  blennorrhea  neonatorum  ;  the  skin  of  the  lower  lid  and  in  the 
region  of  the  inner  eanthus  has  undergone  purulent  infiltration,  and  is 
partially  eroded  by  the  discharge. 

Fig.  2.—"  The  lower  lid  of  the  same  case  inverted,  to  show  the  depth 
to  which  the  diphtheritic  infiltration  of  the  conjunctiva  has  extended; 
it  is  discolored  yellowish  gray."  (From  Haab,  Atlas  of  the  External  Dis- 
eases of  the  Eye.) 

lymph-nodes  are  markedly  infiltrated.  Multiple  die;sem- 
inated — and  sometimes  coalescing — ulcers,  varying  in 
size  from  a  lentil  to  a  bean,  are  seen  on  the  vaginal  mar- 
gins ;  these  ulcerations  are  covered  by  a  grayish-white, 
closely  adherent  deposit.  In  some  cases  the  whole  vulva 
is  covered  by  a  connected  dirty  gray  deposit,  beneath 
which  a  deep-seated  necrosis  exists. 

Complications  and  Sequelse  of  Diphtheria. — The  com- 
monest complications  are  nephritis,  bronchitis,  and  pneu- 
monia. The  sequelae  consist  of  cardiac  weakness  and 
paralyses.  The  danger  of  paralysis  of  the  heart  is  ever 
present  during  the  acute  stage  and  in  convalescence,  and 
requires  the  greatest  care  in  treatment.  The  heart  loses 
its  strength  either  gradually  or  death  due  to  heart  failure 
may  arise  suddenly.  Both  conditions  are  caused  by 
alterations  in  the  cardiac  muscular  fibrilhe,  which,  accord- 
ing to  Eppinger,  are  a  direct  sequel  of  a  toxic  edema  due 
to  the  diphtheritic  virus.  The  postdiphtheritic  paralyses 
are  a  manifestation  of  peripheral  neuritis  whose  course  is 
unaccompanied  by  fever,  pain,  or  paresthesiae.  Recovery 
occurs  almost  without  exception  in  from  four  to  six 
weeks.  The  velum  palati  and  certain  ocular  mu.scles 
are  especially  prone  to  become  paralyzed  ;  more  rarely 
the  muscles  of  the  trunk  and  the  extremities.  Threaten- 
ing life  are  paralysis  of  the  larynx  and  pharynx,  the 
abdominal  musculature,  and  that  of  the  diaj)hragm. 

The  prognosis  of  dipiitheriais  dependent  upon  the  age 
and  strength  of  the  patient  (the  older  the  patient  the 
more  favorable  the  prognosis),  upon  the  character  of  the 
epidemic,  and  the  time  at  which  skilful  scientific  treat- 


Tah.W. 


Firj.l. 


i        ' 


X 


^^ 


Fuj.^. 


DIPHTHERIA  281 

raent  is  obtained.  The  mortality  rate,  when  serum 
therapy  has  been  employed,  is  only  a  small  jKjrcentage 
(von  liauchfuss,  Bayeaux) ;  in  operative  cases  it  equals 
about  36  per  cent.  (Siegert). 

Diagnosis. — The  greatest  difficulty  is  met  with  in  dis- 
tinguishing diphtheritic  from  non-diphtheritic  angina,  and 
laryngeal  diphtheria  from  pseudocroup.  In  the  micro- 
scopic and  bacteriologic  examination,  which  should  be 
resorted  to  in  every  doubtful  case,  we  must  bear  in  mind 
that  the  discovery  of  single  bacillus  on  the  inflamed 
raucous  membrane,  when  the  diphtheria  bacilli  are  spread 
widely  over  the  mucous  membrane  of  a  healthy  jierson,  is 
not  indicative  of  the  diphtheritic  character  of  the  disease, 
for  the  latter  only  holds  true  when  diphtheria  bacilli  are 
found  in  colonies.  On  the  other  hand,  the  diagnosis  of 
diphtheria  in  a  case  which  appears  clinically  to  be  such 
should  not  be  rejected  because  the  specific  bacillus  has 
been  displaced  by  other  bacilli  or  because  it  was  not 
found  by  chance  in  the  examined  material.  For  micro- 
scopic examination  remove  a  bit  of  the  deposit  with  a 
pair  of  forceps,  wash  in  distilled  water,  and  spread  be- 
tween two  cover-glasses.  Fix  over  a  flame.  Stain  with 
Loffler's  methylene-blue.  The  diphtheria  bacilli  are 
slender,  slightly  curved  rods,  about  as  long  but  twice  as 
wide  as  the  tubercle  bacillus;  the  ends  are  often  clubbed 
and  assume  a  characteristic  angular  position.  They 
stain  intensely  with  methylene-blue  and  are  jjeculiarly 
nucleated. 

Treatment.  —  Specific  Treatment :  Serum  Treatment.  — 
The  antitoxin  should  be  injected  as  early  as  possible  in 
the  progressive  form  of  diphtheria  when  signs  of  lar>'n- 
geal  involvement  and  toxic  symptoms  occur,  even  in  the 
mild  types.  The  serum  has  a  local  as  well  as  a  constitu- 
tional action.  It  prevents  further  progress  of  the  l<K?al 
process  and  hastens  the  dissolution  of  the  fibrin.  It  also 
neutralizes  any  diphtheritic  toxin  which  may  be  in  the 
circulation  at  the  time  of  injection.  Failure  to  relieve  is 
due  to  either  a  severe  and  irre{iarable  toxic  action  before 
the  time  of  serum  injection  or  to  a  mixed  infection,  iu 


282  ACUTE  TNFECTIOUS  DISEASES 

FIGURE  93 

Microscopic  findings  in  diphtheritic  angina.  Colonies  of  diphtheria 
bacilli,  isolated  cocci,  and  thready  fibrin.    Enlarged  510  times. 

FIGURE  94 

Microscopic  findings  in  lacunar  angina  which  is  non-diphtheritic  in 
character.  Diffused  bacterial  growth.  Of  the  numerous  varieties  none 
seem  to  predominate.    Spare  fibrin  threads.     Enlarged  510  times. 


which  case  we  can  only  expect  the  antitoxin  to  influence 
the  specific  and  not  the  foreign  virus.  Irrespective  of 
age  the  following  injections  should  be  made  :  In  localized 
diphtheria,  1000  I.  U.  (Behring  II,) ;  in  progressive 
diphtheria  or  with  involvement  of  the  larynx,  1500  I.  U. 
(B.  III.);  in  laryngeal  stenosis  or  severe  intoxication,  2000 
to  3000  I.  U.  (B.  D.  IV.-VI.)  ;  as  a  prophylactic  inject 
600  to  1000  I.  U.  (B.  I.  or  II,), i  [The  above  doses 
may  be  considered  small.  In  a  case  of  clinical  diphtheria 
3000  units  at  least  should  be  given  at  the  onset.  This 
dose  may  be  repeated  at  intervals  of  six  hours  until  some 
effect  is  produced  on  the  membrane. — Ed.] 

The  serum  may  be  injected  with  any  syringe  contain- 
ing 5  cc.  and  which  can  be  ea.sily  sterilized.  For  the 
injection,  a  portion  of  the  skin  should  be  selected  beneath 
which  there  is  loose  subcutaneous  tissue,  as,  for  instance, 
the  side  of  the  chest.  [The  gluteal  region  is  easily 
accessible  when  the  child  is  held  on  the  lap  of  mother  or 
nurse,  and  is  a  favorite  site  for  these  injections. — Ed.] 
The  site  is  thoroughly  cleansed ;  a  fold  of  the  skin  is 
seized  in  the  fingers  and  the  cannula  introduced  parallel 
to  it  to  such  a  depth  that  the  latter  is  freely  movable  in 

'  Tlie  curative  serum  is  usually  obtained  from  horses  which,  after 
careful  preparation  (repeated  injections  of  gradually  increasing  doses 
of  the  diphtheritic  virus),  are  immunized  to  a  hi.nh  degree  against 
diphtheria.  The  value  of  the  antitoxin  thus  obtained  is  determined  by 
its  action  against  tested  solutions  of  the  diphtheritic  virus.  That  amount 
of  serum  which  in  strength  equals  100  times  the  amount  required  to 
neutralize  a  close  of  virus  which  is  fatal  to  guinea-pigs  is  spoken  of  as 
an  immunization  unit  =  I.  U.  If  this  action  is  obtained  in  1  cc.  of  the 
serum,  we  speak  of  a  simple  serum;  if  it  already  exists  in  y^^r  P^'t  <>f 
a  cc,  we  speak  of  100-fold  serum,  etc.  At  the  present  time  250-,  400-, 
and  500-foid  serum  may  be  obtained  on  the  market. 


V\'      -^ 


''^T 


Fig.  93. 


^ .,/ 


•^"^^ 


e 


Fig.  94. 


DIPHTHERIA 


283 


the  subcutaneous  cellular  tissue. 
Before  withdrawing  the  cannula 
a  piece  of  adhesive  plaster  should 
be  applied  to  the  point  of  in- 
jection to  prevent  the  escape  of 
the  serum  and  the  infection  of  the 
wound.  Massage  of  the  swollen 
area  which  results  is  unnecessary. 
Pains  in  the  wound  disappear 
within  twenty-four  hours.  Occa- 
sionally within  the  first  fourteen 
days  after  the  injection  we  may 
note  an  increase  of  fever,  con- 
stitutional disturbances,  and  the 
appearance  of  morbilliform,  scar- 
latina- or  urticaria-like  rashes, 
and,  in  rare  cases,  articular  pains. 
These  ill  effects  of  the  serum  in- 
jection disappear  without  leaving 
any  traces  behind  within  several 
hours  or,  at  the  most,  within  one 
or  two  days.  The  serum  has  no 
other  untoward  effect. 

Local  (ind  Constitutional  Treat- 
ment.— Cleanliness  of  the  mouth  ; 
nasal  douches ;  hydrotherapeutic 
measures ;  neutral  soap-baths  (35° 
C.  [95°  F.]  ),  with  cold  rubbing. 
Light,  stimulating  diet.  The 
nephritis  and  paralyses  usually 
require  no  special  treatment. 

Special  Treatment. — In  nasal 
diphtheria  douche  the  nose  with 
weak  antiseptic  solutions  or  in- 
sufflations of  ])owdered  boric  acid 
or  sodium  sozoiodol.  For  diphthe- 
ria of  the  conjunctiva  make  warm 

Fig.  97. — An  easily  sterilizablc  serum 
syringe  with  a  metallic  piston  (modified 
by  Walcher). 


284 


ACUTE  INFECTIOUS  DISEASES 


FiQ.  98. — The  injection  of  serum  in  the  left  axilln,  ti.e  anus  being 
tightly  supported  on  both  sides,  so  that  the  patient  cannot  interfere  with 
the  operation.  The  cannula  is  introduced,  parallel  to  the  surface  of  the 
body,  into  the  elevated  fold  of  skin. 


Fig.  99. — Intubation  with  elastic  tubes.  As  the  tube  is  being  put 
into  place  it  assumes  the  curvature  of  the  introducer,  which  conforms 
in  shape  to  the  curvature  of  the  tongue.  After  it  has  been  introduced  it 
follows  the  curvature  of  the  laryngotracheal  tube.  (Note  how  the  left 
index-finger,  which  lies  attlieenti-anco  to  the  larynx,  draws  the  epiglottis 
and  root  of  the  tongue  forward  and  ui)ward  in  order  to  exjmse  the 
entrance  into  the  larjnx  as  much  a>s  possible.) 


DIPHTHERIA  285 

applications;  apply  disinfectants  for  dij)htlieria  of  the 
vulva;  after  cleansing,  apply  boric-iodofonn  powder. 
At  the  beginning  of  laryngeal  stenosis  order  a  hot  bath, 
followed  by  sweat-stimulating  packs ;  energetic  vapor 
treatment  in  order  to  reduce  the  inflammatory  swelling 
and  to  hasten  softening  of  the  membrane.  When  the 
stenosis  threatens  life,  resort  to  intubation  (O'Dwyer) 
or  tracheotomy. 

Intubation  consists  in  introducing  into  the  larynx  by 
way  of  the  mouth  a  small  tube  constructed  of  metal,  hard 
rubber,  or  some  elastic  material,  and  allowed  to  remain  in 
place  until  the  local  process  has  undergone  resolution, 
which  is  about  three  days.  The  patient  is  wrap|)ed  from 
neck  to  feet  in  a  sheet,  and  intubated  while  lying  in  bed 
or  sitting  on  the  lap  of  an  assistant,  who  fixes  with  his 
thighs  the  child's  legs,  holds  the  mouth  open  with  one 
hand  and  the  head  in  a  median  position  with  the  other. 
The  tube  is  inserted  by  first  introducing  the  left  index- 
finger  far  into  the  pharynx  to  hold  the  entrance  of  the 
pharynx  open  by  pressing  the  tongue  as  far  forward  and 
upward  as  possible  and  the  epiglottis  against  the  root  of 
the  tongue.  During  this  operation  the  following  precau- 
tions are  necessary  : 

The  instrument  must  be  introduced  in  the  middle  line  to 
avoid  entering  one  of  the  different  lateral  mucous  fossae. 

The  handle  of  the  introducer  should  be  raised  after  the 
epiglottis  is  passed,  in  order  that  the  tube  will  not  glide 
over  the  entrance  of  the  larynx,  which  is  half  covered  by 
the  tongue,  into  the  esophagus. 

After  the  tube  is  inserted  into  the  larynx  the  handle 
should  again  be  lowered  to  avoid  injuring  the  anterior 
wall  of  the  larynx  by  the  tube.  The  operation  should 
last  only  a  few  seconds.  Accidents  during  the  operation 
itself  are  rare,  but,  on  the  other  hand,  difficulty  in 
swallowing,  coughing  the  tube  out,  or  obstruction  of  the 
tube,  and  the  more  extensive  formation  of  pressure 
ulcers  are  more  or  less  serious  accompaniments.  [In  the 
hands  of  experienced  operators  this  procedure  is  not 
difficult,  hence  accidents  are  rare.     In  the  inexperienced, 


286 


ACUTE  IXFECTIOUS  DISEASES 


however,  injuries  to  the  mucosa  of  the  larynx  are  more 
common  than  woukl  be  expected  from  the  literature. — Ed.] 
The  cxtubation  is  performed  cither  by  means  of  a 
pharyngeal  forceps-like  instrument  or,  better,  by  the  use 
of  a  silk  thread,  one  end  of  which  is  fastened  to  the 
head  of  the  tube  and  the  other  end  passing  out  of  the 


Yio.  100. — Intabation  tubes.  Metallic  tubes :  a.  O'Dwyer's  origiual 
tubes,  h.  Bauer's  curved  tubes,  c.  Bayeux' short  tubes.  Rubber  tubes: 
d.  O'Dwyer's  ebony  tubes,    c.  Trumi)p's  elastic  tubes. 

mouth,  which  is  fastened  to  the  cheek  by  means  of  a 
piece  of  adhesive  plaster. 

If  the  existing  conditions  prevent  free  respiration 
through  the  tube  or  if,  for  any  roa.«on,  it  is  impossible  to 
introduce  the  tube,  the  bloody  operation  must  be  substi- 
tuted, and  the  trachea  opened  above  or  below  the  isthmus 
of  the  thyroid. 


Fig.  101.— Intubation  (U'Uwyer's  instrument,  obony  tul)e).  First 
operation  :  Introduction  into  the  mouth.  The  handle  of  the  introducer 
is  depressed. 

287 


Fig    102.-liuubaiiou.      Second  operation:  Insertion  into  the  larynx. 
Handle  of  the  introducer  is  elevated. 

289 

19 


290  ACUTE  INFECTIOUS  DISEASES 

PLATES  31-33 

Tracheotomy 

The  plates  show  the  various  tissues  of  the  neck  which  must  be  severed 
in  tracheotomy.  The  incisions  are  so  presented  as  to  show  simultaneously 
the  important  anatomic  relationships  iu  high  and  low  tracheotomy.  In 
practise  the  skin  incision  iu  high  tracheotomy  is  made  1  cm.  [.4  in.] 
higher  and  in  low  tracheotomy  1  cm.  [.4  in.]  lower  than  is  shown  in  the 
figure. 

Plate  31. — The  skin  has  been  incised  and  the  subcutaneous  cellular 
tissue  exposed.  The  hyoid  bone,  the  thyroid  and  cricoid  cartilages,  the 
trachea,  the  thyroid,  and  thymus  glands  are  traced  iu  dotted  lines  for 
purposes  of  demonstration.  In  palpation  remember  that  in  small  chil- 
dren only  the  hyoid  bone  and  the  cricoid  cartilage  can  be  plainly  felt, 
and  that  the  latter  cartilage  (not  as  in  the  case  of  an  adult,  the  thyroid) 
represents  the  most  prominent  portion. 

Plate  32,  Fig.  1. — The  adipose  tissue  has  been  severed  and  the 
superficial  cervical  fascia  with  the  branches  of  the  inferior  thyroid  vein 
brought  into  view.  The  musculature  with  the  linea  alba  is  seen  to  shine 
through  the  fascia. 

Fig.  2. — The  superior  cervical  fascia  has  been  incised  and  the  sterno- 
hyoid muscles,  which  are  joined  in  the  median  line  by  the  linea  alba, 
exposed. 

Fig.  3. — The  musculature  has  been  cut  and  the  deep  cervical  fascia 
exposed. 

Fig.  4. — The  superficial  layers  of  the  deep  cervical  fascia  are  incised, 
and  we  see  exposed  at  the  upper  portion  of  the  wound  the  isthmus,  which 
is  about  1  cm.  [.4  in. J  wide,  and.  to  a  certain  extent,  the  lateral  lobes  of 
the  thyroid  gland,  also  the  anastomosis  of  the  inferior  and  superior 
thyroid  veins.  The  thymus  gland,  which  protrudes  markedly  upward, 
is  seen  at  the  lower  end  of  the  wound.  Loose  cellular  tissue  and  the 
deep  layers  of  the  cervical  fascia  lie  between  the  thyroid  and  thymus 
gland,  also  the  anastomosis  of  the  inferior  thyroid  with  the  anterior 
jugular  vein. 

Plate  33.  Low  Tracheotomy.  —Cellular  tissue  and  the  deep  layers  of 
the  cervical  fascia  are  severed  and  the  trachea  exposed  between  the 
thyroid  and  thymus  glands.  To  the  left  of  the  lower  portion  of  the 
wound  is  the  innominate  artery,  which  is  in  a  high  position.  (The  in- 
nominate, as  a  rule,  occupies  a  high  position  in  children  during  the  first 
year  of  life,  also— as  is  not  rarely  the  case— during  the  second  and  third 
years.    This  must  be  remembered  to  avoid  injuring  it.) 

The  patient  is  wrapped  in  a  sheet  (as  in  case  of  intuba- 
tion), placed  on  a  table,  and — in  order  to  obtain  full 
extension  of  the  neck — a  bottle  wrapped  in  cloth  is  placed 
underneath  it.  An  assistant  attends  to  the  anesthetiza- 
tion (which  in  profound  carbonic-acid  intoxication  is 
unnecessary)  and  watclies  the  neck  of  the  child  during 
the  operation,  in  order  to  prevent  lateral  movement  or 


Tab..V. 


lnb.3J. 


Fiql. 


Filf.  ai. 


FiH-'i. 


f-'in    J 


Tab.i 


DIPHTHERIA  291 

displacement.  The  same  asepsis  is  necessary  as  in  any 
other  bloody  operation.  The  incision  of  the  skin  as  well 
as  that  of  the  other  tissues  should  be  exactly  in  the 
median  line.  The  opening  in  the  skin  should  be  at  least 
5  cm.  [2  in.]  long  and  reach,  in  case  of  superior  tracheot- 
omy, to  the  chin  ;  in  the  case  of  inferior  tracheotomy,  to 
the  sternum.  The  subcutaneous  tissue  is  retracted  by 
means  of  two  artery  forceps;  next  the  superficial  fascia 
and  beneath  it  the  glistening  linea  alba  of  the  sternohyoid 
muscles  are  severed  on  a  grooved  director.  The  next 
step  differs  in  high  and  low  tracheotomy.  In  the 
former,  a  transverse  incision  is  made  through  the  deep 
cervical  fascia,  which  lies  ex})osed  beneath  the  muscles, 
to  the  lower  edge  of  the  cricoid  cartilage.  It  is  then 
loosened  by  blunt  dissection  and  drawn  upward  together 
with  the  enclosed  thyroid  gland  to  expose  the  trachea. 
In  low  tracheotomy  the  cervical  fascia  is  incised  in  a 
longitudinal  direction,  layer  by  layer,  on  a  grooved  direc- 
tor until  the  thyroid  gland  is  reached.  After  the  deepest 
layer  has  been  severed,  the  trachea,  which  lies  partially 
exposed,  is  caught  by  two  sharp  hooks  and  drawn  up- 
ward and  freed  by  blunt  dissection  of  any  loose  cellular 
tissue  which  may  still  adhere.  A  sharp-pointed  knife  is 
now  forced  through  the  trachea  until  the  hissing  sound 
of  the  escaping  air  informs  us  that  the  tracheal  lumen 
has  been  opened ;  the  incision  is  then  sufficiently  enlarged 
with  a  probe-pointed  bistoury  to  permit  the  entrance  of 
the  cannula,  that  is,  from  1  to  1.5  cm.  [.4-.6  in.].  Not 
until  the  breathing  has  become  absolutely  free  is  the  can- 
nula (with  a  movable  shield,  as  recommended  by  Liier  or 
Hagedorn)  introduced  and  fastened  to  the  neck  with  a 
simple  band.  The  wound  is  well  dusted  with  iodoform 
and  covered  with  a  piece  of  lint  or  gauze  to  receive  the 
expelled  tracheal  secretion,  and  also  with  a  piece  of  gutta- 
percha or  a  piece  of  cambric. 

Difficultv  may  be  encountered  in  performing  this 
operation  by  the  presence  of  an  abnormally  large  thyroid 
gland,  or  its  close  union  with  the  trachea,  a  large  thymus, 
numerous  congested  venous  branches,  and  (in  rare  cases) 


292  ACUTE  ISFECTIOUS  DISEASES 

arterial  anomalies.  The  after-treatment  is  complicated 
by  the  j)resence  of  post-operative  hemorrhages,  dysphagia, 
obstruction  of  the  cannula,  and  decubitus. 

For  the  sake  of  cleanliness  the  cannula  must  be  changed 
on  the  third  day.  To  do  so,  retract  the  soft  parts  which 
are  still  ununited  with  hooks  and  pass  a  catheter,  with  a 
hirge  opening,  through  the  cannula  into  the  trachea  and 
employ  it  as  a  conductor  for  the  removal  of  the  old  and 
introduction  of  the  new  cannula.  In  one  or  two  days  a 
speech-cannula  is  inserted,  and  by  closing  the  same  the 
permeability  of  the  larynx  may  be  tested.  If  the  child 
])asses  through  a  night  well  and  sleeps  undisturbed  the 
closed  speech-cannula  may  be  removed  and  the  wound 
allowed  to  heal, 

TYPHOID  FEVER 

Tyj)hoid  fever  is  an  infectious  disease  which  is  primarily 
localized  in  the  intestines  and  accompanied  by  swelling 
of  Peyer's  patches  and  of  the  spleen.  It  occurs  in  chil- 
dren, especially  after  five  years  of  age,  almost  as  frequently 
as  in  adults. 

The  morbid  anatomy  as  well  as  the  symptom-complex  is, 
on  the  whole,  the  same  in  older  children  as  in  adults,  but 
in  younger  children  there  is  a  decided  difference.  In  tlie 
latter  the  u])per  portions  of  the  intestine  are  chiefly  in- 
volved and  the  morbid  ])rocess  is  not  as  deeply  seated, 
accordingly  necrotic  eschars,  extensive  typhoidal  ulcers, 
and  intestinal  j)erforation  are  rare  in  children. 

Clinically,  we  frequently  note  in  place  of  the  tyj)ic 
diarrhea  (pea-soup  stooh)  an  obstinate  constipation,  with 
])artly  pap|)y  and  partly  hard  nodular  stools.  In  other 
respects  the  disease  j)icture  represents  the  mild  typhoid 
of  adnlts  (ffciMric  fever) :  Dyspepsia,  headache,  remittent 
fever,  slight  swelling  of  the  spleen,  and  sometimes  rose- 
ola. The  manifestations  are  frequently  so  slightly 
characteristic  of  ty])hoid  that  the  diagnosis  remains 
doubtful,  and  is  only  made  possible  by  severe  relapses 
or  by  etiologic  relationship  with  other  nndoubted  cases 
of  typhoid  fever.     Sometimes  the  condition   passes  into 


TYPHOID  FEVER 


293 


a  form  of  moderate  severity  which  is  accompanied  by 
an  initial  pseudomembranous  angina,  epistaxis,  cerebral 
irritation,  diarrhea,  dry  bronchitis,  and  marked  loss  of 
strength.  The  severe  type  of  typhoid  in  children  does 
not  differ  much  either  in  its  course  or  complications  from 
that  disease  in  adults;  children,  however,  complain  more 
frequently  of  abdominal  pain,  the  nervous  symptoms  are 
more  prominent,  and  the  whole  duration  of  the  disease  is, 
in  general,  shorter. 


Fastigium.  Typic  defervescence 

of  a  remission  by  lysis. 
Fk4.  103.— The  type  of  fever  in  typhoid  fever  of  childhood  (Gerhardt- 

Seiflfert). 

The  diagnosis  is  made  from  the  characteristic  step- 
ladder-like  ascent  of  the  fever,  the  roseolar  rash,  enlarge- 
ment of  the  spleen,  absence  of  leukocytosis  (Baginsky) 
(leukocytosis  in  pneumonia),  diazo-reaction  of  the  urine, 
Gruber-Widal  reaction  (agglutinating  action  of  diluted 
blood-serum  from  a  typhoid  patient  upon  the  typhoid 
bacillus). 


294  ACUTE  INFECTIOUS  DISEASES 

The  prognosis  in  children  is,  on  the  whole,  more  favor- 
able than  in  adults. 

Treatment. — The  strictest  observation  of  all  hygienic 
measures,  especially  as  regards  cleanliness  of  the  mouth. 
Baths  from  three  to  six  times  daily  at  a  temperature  of 
from  30°  to  35°  C.  [86°-95°  F.]  and  of  five  to  ten 
minutes'  duration,  during  which  the  child  is  energetically 
rubbed  and  finally  douched  with  water  which  has  been 
cooled  off  by  means  of  ice.  The  number  and  temperature 
of  the  baths  depend  less  upon  the  degree  of  fever  than 
upon  the  severity  of  the  attack  (Heubner).  In  case  of 
very  high  fever  and  severe  diarrhea  make  cold  applica- 
tions to  the  chest  and  abdomen,  which  are  changed  every 
fifteen  minutes.  Give  large  quantities  of  liquids  and 
limit  to  a  milk  or  carbohydrate  diet. 

INFLUENZA 

Influenza  in  children  is  characterized  by  attacks  of 
high  fever,  an  initial  retropharyngitis,  and  toxic  constitu- 
tional symptoms  which  are  especially  referable  to  the 
gastro-intestinal  canal,  the  nervous  system,  and,  to  a 
less  extent,  the  respiratory  organs.  The  bacillus  of  in- 
fluenza seems  to  attack  by  preference  the  mucous  mem- 
brane of  the  postpharyngeal  wall,  from  whence,  after 
an  incubation  period  of  from  one  to  eight  days,  it  dis- 
tributes its  poisonous  metabolic  products  throughout  the 
whole  organism.  Prodromal  manifestations  are  usually 
absent. 

Symptoms. — The  disease  begins  with  the  development 
of  pronounced  weakness,  headache,  sometimes  chills,  and 
a  high  remittent  fever  which  often  lasts  but  two  or  three 
days.  Inspection  of  the  pharynx  discloses  a  diffuse  red- 
ness of  the  dry  mucosa,  a  retropharyngitk  (Soltmann). 
Pain  develops  in  the  neck,  back,  joints,  and  head,  where 
it  is  very  severe.  The  appetite  is  lost,  the  pulse  is  small, 
rapid,  and  at  times  arhythmic.  Not  rarely  symptoms  of 
cardiac  weakness  and  mild  cyanosis  are  met  with.  The 
remaining  symptoms  depend  largely  upon  the  age  of  the 


INFLUENZA  295 

child.  In  older  children  as  well  as  in  adults  the  phe- 
nomena of  a  descending  catarrh  of  the  respiratory  tract 
exist;  frequently  also  an  influenzal  croup  (descending 
croup  with  exceptionally  tenacious  expectoration).  On 
the  other  hand,  in  younger  children  the  dyspeptic  or 
enteritic  (Baginsky,  Schlossmann)  and  cerebral  symptoms 
predominate  (diarrheic,  mucous  stools  of  a  foul  odor, 
sometimes  the  typhoidal  state,  slight  enlargement  of  the 
spleen,  coma,  delirium,  meningitic  symptoms  or  true 
primary  influenzal  meningitis,  due  to  infection  of  the 
blood  by  the  bacillus  of  influenza). 

The  bronchial  and  pulmmiary  phenomena  in  influenza 
show  a  remarkable  and  characteristic  resistance  toward 
the  ordinary  therapeutic  measures.  They  are,  in  general, 
not  of  a  serious  character ;  however,  ca.ses  of  broncho- 
pneumonia are  met  in  which  the  confluence  of  lobular 
foci  lead  to  consolidation  of  whole  lobes,  and  death  may 
even  occur,  due  to  abscess  or  necrosis.  Influenza  fre- 
quently involves  the  tympanic  cavity,  in  which  case 
hemorrhagic  inflammation  of  the  tympanum  and  suppura- 
tion of  the  middle  ear  almost  always  develop  (Hartman, 
Heubner).  Conjunctivitis  and  extreme  photophobia  are 
not  rare  complications  (Spiegelberg,  Comby).  In  about 
12  per  cent,  we  note  the  development  of  a  measles-like, 
roseolar,  or  scarlatinal  eruption  (Schlossmann),  and,  more 
rarely,  nephritis. 

The  duration  of  the  disease  is  from  three  days  to  as 
many  weeks  and,  rarely,  longer. 

The  prognosis  is,  on  the  whole,  more  favorable  than  in 
adults. 

The  diagnosis  may  be  made  in  questionable  cases  from 
catarrh,  bronchitis,  pneumonia,  and  meningitis  by  the 
detection  of  the  bacilli  of  influenza.  The  latter  are 
minute  rods,  usually  occurring  in  pairs,  which  lie  in  large 
groups  between  the  pus-corpuscles  and  frequently  also 
within  the  cells.  Doubt  as  to  the  influenzal  nature  of 
gastro-intestinal  sym])toms  may  be  settled  by  the  as- 
sociated joint  and  muscle  pain  and  headache. 

Treatment. — Symptomatic   (at   the   beginning   of  the 


296  ACUTE  INFECTIOUS  DISEASES 

disease  procedures  which  increase  perspiration  may  be 
indicated).  Give  as  many  decigrams  of  quinin  twice  daily 
as  the  patient  is  old  in  years. 

WHOOPING-COUGH.    PERTUSSIS 

Whooping-cough  is  a  catarrhal  aifection  of  the  upper 
air-passages  occurring  in  epidemics,  which  is  character- 
ized by  marked  irritation  of  the  respiratory  mucous 
membrane,  and  especially  by  attacks  of  coughing,  accom- 
panied by  a  prolonged  crowing  inspiration  which  occurs 
frequently  at  night. 

The  laryngoscopic  and  pathologic  findings  consist  of  a 
catarrh  of  the  upper  air-passages  extending  into  the 
large  bronchi,  accompanied  by  redness,  swelling,  and 
softening  of  the  mucous  membrane,  with  the  excretion  of 
an  extremely  tenacious  discharge,  which  is  rich  in  mucin 
and  contains  varying  quantities  of  pus-cells.  The  great- 
est degree  of  reddening  is  noted  in  the  interarytenoid 
space  and  at  the  bifurcation  of  the  trachea.  Laryngo- 
scopic examination  shows  these  areas  to  be  particularly 
irritated,  and  that  the  passage  over  them  of  the  tenacious 
mucus  flakes  Causes  the  typic  spasmodic  attacks  of  cough- 
ing. The  characteristic  changes  in  the  lungs  consist  of 
ecchymoses  of  the  pulmonary  cortex,  acute  distention  of 
the  apices,  emphysema,  and  distention  of  the  bronchioles. 
The  latter  contain  a  thick,  creamy  pus,  which  at  times 
finds  its  way  into  the  alveoli,  these,  through  violent  in- 
spiration of  the  secretion  (into  the  formerly  collapsed 
alveoli),  become  dilated  to  the  size  of  a  j)in  head  or  jiea 
(Fauvel,  Ziemssen).  Dilatation  and  hypertrophy  of  the 
right  heart  is  nearly  always  present  (due  to  increased  pres- 
sure in  the  pulmonary  circulation).  The  clinical  manifes- 
tations at  the  beginning  and  during  the  stage  of  decline 
show  little  that  is  characteristic.  We  distinguish  between 
an  initial  catarrhal  stage,  a  catarrhal  convalescent  stage, 
and  the  interval  between  them,  or  the  convulsive  stage. 

The  perio<l  of  incubation  lasts  from  three  to  ten  days 
and  is  symptomless. 


WHOOPING-COUGH.      PERTUSSIS  297 

Symptoms. — The  initial  catairhal  stage  is  marked  by 
the  symptoms  of  a  febrile  laryugo-traeheo-l)ronciiitis, 
which  resists  the  treatment  of  an  ordinary  catarrh. 
Toward  the  end  of  the  initial  stage  the  catarrhal  symp- 
toms gradually  disappear,  and  the  cough,  which  is  at 
times  loose  and  at  other  times  dry,  assumes  a  peculiar 
metallic  tone.  It  occurs  more  frequently  at  night  and 
becomes  more  spasmodic.  The  initial  and  frequently 
iiigh  fever  sinks  after  a  few  days,  as  a  rule,  to  normal, 
and  the  constitutional  symptoms  lessen  in  severity. 

In  about  two  weeks  after  the  commencement  of  the 
first  symptoms  of  the  disease  the  attacks  of  cough  de- 
velop less  often,  but  are  of  a  convulsive  character— con- 
vulsive  stage.  The  convulsions  are  preceded  for  several 
seconds  or  a  minute  by  an  aura  in  the  form  of  a  tickling 
sensation  or  burning  of  the  throat,  a  feeling  of  oppres- 
sion, great  restlessness,  nausea,  and  tracheal  rattling. 
The  cough,  which  has  been  vainly  held  back,  then  breaks 
forth  ;  numerous  expiratory  coughs  follow  each  other, 
interrupted  only  now  and  then  by  a  laborious,  sighing, 
and  crowing  inspiration,  which  follows  at  times  a  short 
period  of  rest.  This  is  continued  until  the  main  attack 
and  two  or  three  after-attacks  (Reprise,  Baginsky)  have 
forced  out  a  tenacious  plug  of  mucus,  which  frequently  fails 
to  occur  until  one  to  five  minutes  after  a  vomiting  spell. 
During  the  attack,  in  which  the  child  is  frequently  close 
to  asphyxiation,  the  venous  stasis  causes  the  lips  and  eye- 
lids (the  latter  is  often  present  even  after  the  attack)  to 
swell  and  the  face  to  become  red  and  finally  cyanosed. 
The  pulse  is  very  rapid,  in  many  cases  hemorrliages  are 
noted  from  the  nose  and  ear  or  into  the  conjunctivae  and, 
in  rarer  cases,  into  the  brain,  accompanied  by  the  symp- 
toms of  cerebral  pressure  and  even  death.  (A  series  of 
venous  complications  of  whooping-cough  is  attributed  by 
Neurath  to  toxic  inflammation  of  the  meninges.)  The 
child  soon  recovers  after  the  attack,  and  in  uncomplicated 
cases  feels  perfectly  well  during  the  interval.  Examina- 
tion of  the  lungs  is  negative  or  discloses  a  few  dry  rales. 

The  duration   of  the   interval   is   most   variable.     In 


298  ACUTE  INFECTIOUS  DISEASES 

mild  cases  only  about  a  dozen — and  in  severe  cases 
several  dozen — attacks  occur  within  twenty-four  hours. 
In  the  latter  case  the  child,  especially  when  raised  under 
unfavorable  circumstances  of  life,  fails  in  general  health, 
its  sleep  is  disturbed  by  the  frequent  attacks,  and  the 
repeated  vomiting  interferes  with  nutrition. 

After  the  convulsive  stage  has  lasted  two  or  three  and 
sometimes  eight  or  ten  weeks,  the  attacks  begin  to  become 
less  frequent  and  lessen  in  severity.  The  cough  gradually 
loses  its  spasmodic  nature  and  becomes  looser,  and  the 
disease  passes  into  the  terminal  catarrhal  stage,  the  dura- 
tion of  which  depends  upon  external  hygienic  and 
climatic  conditions.  Relapses  during  convalescence  be- 
cause of  neglect  are  quite  frequent. 

The  prognosis  of  pertussis  in  small,  weakly,  especially 
rachitic  children,  is  very  dubious,  because  of  the  fre- 
quency of  severe  com])lications,  such  as  eclampsia,  capil- 
lary bronchitis,  bronchopneumonia,  and  sometimes  puru- 
lent meningitis.  Danger  of  asphyxiation  during  an 
attack  is  especially  likely  to  threaten  nurslings,  for  in 
them  the  seizures  are  less  noisy  and  frequently  the  crow- 
ing inspiration  is  replaced  by  a  sneezing  sound  (at  times 
also  in  older  children  [Hagenbach] ),  and  not  rarely 
decided  air  hunger  already  exists  before  attention  is 
attracted  to  the  child's  condition.  Older  children  present 
an  obstinate  catarrh  of  the  respiratory  organs,  bronchiec- 
tasis, and,  as  a  frequent  sequel,  tuberculosis ;  less  rarely, 
otitis  and  nephritis.  A  doubtful  prognosis  is  always 
made  in  mixed  infection,  as  in  the  occurrence  of  measles, 
rotheln,  scarlet  fever,  and  diphtheria. 

The  diagnosis  is  easily  made  if  a  typic  coughing  spell 
is  heard  ;  in  some  cases  it  is  possible  to  artificially  excite 
such  an  attack  by  pressure  upon  the  root  of  the  tongue 
or  on  the  larynx  (pressure  u]K>n  the  vocal  cords  by  means 
of  the  index-finger  introduced  through  the  mouth 
[Variot]  ).  Of  diagnostic  significance  is  a  bloated  face 
with  the  presence  of  a  doubtful  cough,  also  the  existence 
of  ulcerations  upon  the  frenum  of  the  tongue,  due  to  the 
wedging  of  that  organ  between  the  teeth  during  an  attack. 


MUMPS.     EPIDEMIC  PAROTITIS  299 

The  urine  is  of  high  specific  gravity  and  the  amount  of 
uric  acid  is  increased  (Hippius-Briimenthal).  Finally, 
the  anamnesis  of  the  jKitient  is  of  assistance  in  reaching 
a  diagnosis. 

Treatment. — Provide  fresh,  not  too  cold  or  dry,  and, 
above  all,  dust-free  air.  For  this  purpose  the  child 
should  live  alternately  in  two  rooms  during  the  febrile 
initial  stage  when  rest  in  bed  is  necessary,  as  well  as 
later  throughout  the  course  of  the  disease  when  the 
weather  is  unfavorable.  These  rooms  must  be  constantly 
well  ventilated  and  properly  heated  (the  two-room  treat- 
ment of  Wertheimber).  To  supply  the  air  with  the 
proper  degree  of  moisture  employ  cloth  hangings  which 
have  been  immersed  in  a  carbolic  acid  solution ;  and  the 
floor  should  be  wiped  repeatedly  each  day  with  the  same 
solution.  If  the  out-door  air  j)resents  the  necessary 
requirements  (later  a  change  of  climate)  the  warmly 
dressed  child  should  spend  as  much  time  outside  of  the 
house  as  possible.  Aromatic  baths  (hayseed,  camomile). 
Hardv  children  should  receive  dailv  baths  at  a  tempera- 
ture of  35°  C.  [95°  F.],  followed  while  in  the  bath  by 
cold  rubbing.  An  easily  digestible  diet  with  prohibition 
of  dry  and  strongly  sweetened  food.  In  case  of  frequent 
vomiting  give  small  portions  of  food  in  the  form  of  gruel 
every  half  hour  or  every  hour. 

MedicanienU. — Quinin,  euquinin  (expensive), antitussin, 
pertussin,  bromoform,  and  for  older  children  use  extract 
of  belladonna  together  with  codein  or  morphin.  In- 
halations of  oil  of  cypress  (Soltmann)  or  of  a  2.5  ]>er 
cent,  solution  of  carbolic  acid.  Administer  alkaline 
waters.  The  bromids  in  large  doses  and  enemata  of 
chloral  are  indicated  for  eclampsia. 

MUMPS.     EPIDEMIC  PAROTITIS 

Mumps  is  an  acute  febrile  and  contagious  swelling  of 
the  parotid  glands  and  surrounding  structures. 

The  incubation  period  lasts  from  one  to  three  weeks 
and  is  symj)tomless. 


300  ACUTE  INFECTIOUS  DISEASES 

Fig.  104. — Epidemic  parotitis.  Second  day.  The  picture  shows  the 
uniform  swelling  in  the  region  of  the  left  ear,  which  has  spread  to  the 
fiice  and  the  submaxillary  areas;  also  the  characteristic  elevation  of  the 
auricular  lobule.  The  filling  of  the  fossa  between  the  mastoid  process 
and  the  ramus  of  the  lower  jaw  is  unfortunately  not  visible.  (See  Fig. 
107,  cervical  lymphadenitis.) 


The  prodromal  phenomena  consist  of  general  uneasiness 
which  in  a  few  days  leads  to  a  local  disturbance.  The 
child  experiences  a  painful  drawing  sensation  in  the 
region  of  the  car,  and  finds  that  chewing  and  swallowing 
are  somewhat  interfered  with.  Simultaneously  with  these 
symptoms  a  swelling  is  noted  below  the  lobule  of  the  ear, 
which  rapidly  spreads  forward  to  the  region  of  the  par- 
otid gland.  Sometimes  collateral  edema  involves  the 
neighborhood,  including  the  whole  side  of  the  face  as  far 
as  the  nose  and  orbits,  and  the  neck  as  far  as  the  distal 
end  of  the  clavicle.  The  swelling  causes  a  characteristic 
elevation  of  the  auricular  lobule  and  distortion  of  the 
face,  which  increases  decidedly  in  width.  In  from  two 
to  four  days  the  affection  also  spreads  frequently  to  the 
other  parotid  gland,  in  which  case  the  extensive  swelling 
of  both  sides  meet  l)elow  the  jaws  and  give  the  face  a 
comical,  pear-shaped  appearance.  Tlie  skin  over  the 
swollen  portions  of  the  gland  remains  pale,  although 
occasionally  it  may  be  slightly  reddened.  The  parotid, 
the  sublingual,  and  submaxillary  glands,  as  well  as  tho.se 
at  the  angle  of  the  jaw  (which  may  likewise  be  involved), 
are  sensitive  to  pressure  and  may  be  plainly  felt  through 
the  swelling  (which  is  elsewhere  fairly  soft  and  doughy) 
as  dense  nodules. 

The  painfulness  of  the  inflamed  glands  and  the  pres- 
sure of  the  swelling  upon  the  deeji-lying  soft  parts 
re})resent  the  chief  disturbances.  Movement  of  the 
head  is  limited ;  troublesome  swallowing  and  ear-ache 
are  present.  As  a  rule,  an  initial  fever  of  38.5°  C. 
[100.9°  F.]  occurs;  only  rarely  is  the  temperature 
higher;  frequently  lacunar  angina  and  fetor  of  the  breath 
coexist.  The  swelling  begins  to  diminish  after  two  or 
.  three  days  and  disappears  in  about  eight  days.    Recovery 


MUMPS.      EPIDEMIC  PAROTITIS 


301 


"^Wp^*"      >% 


Fig.  lui. 


302  ACUTE  INFECTIOUS  DISEASES 

is  decidedly  delayed  in  involvement  of  both  the  parotid 
glands.  It  is  worthy  of  note  that  in  exceptional  cases  in 
place  of  involvement  of  the  parotid  the  submaxillary 
glands  are  alone  involved — submaxillary  mumps. 

Mumps  is  not  rarely  complicated  by  middle-ear  dis- 
ease, which  may  residt  in  complete  and  incurable  deaf- 
ness; also  by  nephritis.  Metastasis  to  the  testes  and 
ovaries  occurs  only  exceptionally  in  children. 

Diagnosis. — Parotitis  must  be  differentiated  from  lymph- 
adenitis when  it  exists  in  the  region  of  that  gland. 
The  swelling  is  similar  in  both  conditions  at  the  begin- 
ning, excepting  that  in  case  of  lymphadenitis  it  is  not 
localized  so  exactly  between  the  mastoid  process  and  the 
angle  of  the  lower  jaw,  it  grows  more  slowly  and  pre- 
sents, as  it  becomes  more. tense,  reddening  of  the  skin, 
and,  finally,  fluctuation  if  an  abscess  forms  (suppuration 
is  rare  in  epidemic  parotitis).  The  displacement  of  the 
auricular  lobule,  which  is  so  characteristic  of  parotitis,  is 
also  absent  in  lymphadenitis.  Inspection  and  digital 
examination  of  the  oral  and  pharyngeal  cavities  precludes 
the  possibility  of  mistaking  parotitis  for  the  secondary 
edematous  swelling  of  stomatitis,  alveolar  periostitis,  and 
retropharyngeal  abscess. 

The  prognosis  is  favorable  provided  no  complications 
arise. 

Treatment. — Rest  in  bed  during  the  fever  and  confine- 
ment to  the  room  until  the  swelling  has  completely 
disappeared.  Cleanliness  of  the  mouth  is  important,  as 
is  also  a  liquid  or  semiliquid,  non-irritating  diet,  because 
of  difficulties  in  swallowing  and  of  the  danger  of  neph- 
ritis. Depletion  by  way  of  the  intestines.  The  swelling 
is  covered  with  zinc  powder  or  rice  flour  and  protected 
with  cotton.  In  case  of  pain  resort  to  rubbing  with 
heated  oil  of  hyoscyamus,  and  with  potassium  iodid 
ointment  or  6  per  cent,  iodovasogen  if  resorption  is  de- 
layed. 


DISEASES  OF  THE   CIRCULATORY 
APPARATUS 

GENERAL  CONSIDERATIONS 

Diseases  of  the  arteries  in  childhood  are  very  rare, 
but,  on  the  contrary,  pathologic  changes  in  the  heart, 
especially  after  the  fifth  year  of  life,  are  quite  frequent. 
Such  alterations  are  mainly  due  to  infections  or  to  toxic 
influences  (atheromatous  processes  do  not  occur  in  chil- 
dren). [Atheroma  is  found  in  congenital  syphilis.]  As 
causal  conditions  we  have  the  acute  infectious  diseases 
and,  above  all,  acute  articular  rheumatism  (which  is 
known  to  attack  children  even  during  the  nursing 
period),  also  rheumatic  conditions,  which  are  ap})arently 
of  a  mild  type,  such  as  angina,  for  which  reason  the 
heart  should  always  be  examined  in  those  diseases. 

The  congenital  anomalies  of  the  heart,  which  are  not 
very  numerous,  are  attributed  to  disturbances  in  de- 
velopment which  alone  affect  the  circulatory  apparatus, 
or  more  frequently  but  simultaneously,  also  other  organs 
(deformities  of  all  varieties,  hare-lip,  situs  inversus,  etc.). 
Such  anomalies  may  also  follow  fetal  endocarditis  (the 
transmission  of  the  infectious  micro-organisms  from  the 
maternal  blood  to  the  fetal  circulation),  which  frequently 
causes  permanent  changes  in  the  heart  valves,  and  may 
be  associated  by  a  certain  genetic  relationship  with  mal- 
formations of  the  heart  due  to  arrested  development. 

The  sipnpfomatologif  of  cardiac  diseases  in  children 
presents  fewer  characteristics  than  in  adults.  On  account 
of  the  more  efficient  supply  of  blood  to  the  heart  mus- 
culature and  the  physiologic  tachycardia  we  note  that : 

Disturbances  of  compensation  occur  more  rarely  and 
later,  and  that,  therefore,  dropsy  and  secondary  changes 

303 


304  CIRCULATORY  DISEASES 

in  the  liver,  kidneys,  spleen,  and  lungs  are  only  rarely 
observed. 

Congenital  as  well  as  acquired  affections  of  the  heart 
may  exist  for  a  time  without  influencing  in  any  way  the 
heart  dulness,  so  far  as  percussion  can  detect.  These 
reasons,  together  with  the  better  nourishment  of  the 
heart,  probably  contribute  in  making  the  prognosis  of 
acquired  heart  disease  during  childhood  more  favorable 
than  in  later  life  (Hochsinger). 

The  knowledge  of  certain  peculiarities  of  the  infantile 
heart  is  requisite  in  establishing  a  diagnods  of  cardiac 
disease  in  children.  The  apex-beat  during  the  first  or 
second  year  of  life  lies  about  2  cm.  [.8  in,]  outside  of  the 
left  mammillary  line  in  the  fourth  interspace,  and  moves 
during  the  course  of  years  to  the  right  and  downward,  so 
that  after  the  fourth  year  it  is  located  in  the  fifth  inter- 
space, at  first  in  the  mammillary  line,  but  later  within 
that  line. 

The  absolute  cardiac  dulness  in  the  first  year  of  life 
reaches  above  to  the  lower  border  of  the  third  rib,  to  the 
left  mammillary  line,  and  to  the  left  border  of  the  ster- 
num. While  the  outer  and  inner  borders  of  the  heart 
remain  stationary,  the  upper  edge  extends  at  the  age  of 
four  years  to  the  upper  edge  of  the  fourth  rib,  and  in  the 
twelfth  year  to  the  lower  edge  of  the  fourth  rib. 

The  relative  cardiac  dulness  reaches  in  the  first  year 
above  to  the  second  rib,  to  the  left  somewhat  beyond  the 
apex-beat,  to  the  right  as  far  as  the  right  parasternal 
line.  The  upper  border  moves  gradually  downward 
until  the  twelfth  year  to  the  third  rib,  and  its  inner 
border  moves  during  the  .same  time  to  the  right  sternal 
border. 

In  auscultating  note  that,  first,  up  to  the  second  year 
the  first  sound  is  normally  accentuated  everywhere ; 
second,  in  easily  excitable  children  the  first  15  to  20 
heart-beats  at  the  beginning  of  the  examination  are  ac- 
companied by  the  so-called  "cardiac-pulmonary  mur- 
mur" (jerky  exaggeration  and  weakening  of  the  inspira- 
tory murmur  in  the  medial  pulmonary  cortex  caused  by 


CONGENITAL  HEART  DISEASE  305 

the  rhythmic  movements  of  the  heart,  with  whicli  they 
are  .synciironous  ;  most  evident  when  the  heart's  action  is 
vigorous  and  rapid  and  the  respiration  rate  is  increased  in 
frequency) ;  and  third,  the  so-called  accidental,  inorganic 
cardiac  murinurs,  heard  in  children  during  the  first  three 
years,  are  very  rare ;  and  a  systolic  cardiac  murmur  is 
almost  a  positive  indication  of  the  existence  of  organic 
heart  disease,  even  when  it  represents  the  only  demon- 
strable clinical  heart  symptom  (Hochsinger). 

CONGENITAL   HEART  DISEA5E 

Cardiac  monstrosities,  like  acardia,  ectopia  cordis,  etc., 
are  of  no  interest  to  clinicians,  and  only  those  anomalies 
in  which  the  children  continue  to  live  for  a  longer  or 
shorter  period  of  time  need  be  considered.  As  a  rule, 
these  cases  represent  a  combination  of  disease  forms ; 
thus,  anomalies  of  circulatory  communications  show  a 
causal  relationship  *  to  narrowing  of  the  large  arterial 
trunks,  for  example,  congenital  pulmonic  stenosis,  a 
persisting  ductus  Botalli,  and  a  defect  of  the  septum  ; 
typic  cases  of  single  malformations  are  much  less 
common.  (The  fetal  heart  offers  the  current  of  blood, 
which  seeks  to  overcome  an  obstruction  in  circulation, 
various  other  paths  of  exit.)  Indeed,  depending  upon 
the  extent  and  nature  of  the  lesion,  it  may  remain  un- 
noticed for  a  long  time  (frequently  so  during  the  first 
half  year  of  life),  and  the  patient  may  pass  through  life 
without  any  symptoms  of  heart  disease,  or,  on  the  other 
hand,  decided  disturbances  of  circidation  may  already 
exist  at  birth. 

Diagnosis. — The  diagnosis  between  congenital  and  ac- 
quired cardiac  defects  is  not  always  easy.  A  congenital 
anomaly  is  detected  by — 

(1)  A  loud  systolic  murmur  which  is  heard  over  the 
whole  heart  with  no  demonstrable  points  of  maximum 
intensity.  (Localization  by  auscultation  in  endocarditis 
is  probably  possible.) 

(2)  Cyanosis  in  association  with  heart  murmurs.     This 

20 


306  CIRCULATORY  DISEASES 

does  not  arise  in  all  cases,  but  only  in  those  where  ob- 
struction to  circulation  in  the  left  or  right  heart  causes  a 
damming  back  of  the  venous  blood.  In  these  affections 
cyanosis  does  not  progress  with  the  develoj)ment  of 
edema,  as  in  acquired  heart  disease,  nor  is  it  always 
present  at  birth,  but  fails  to  arise  until  months  and  years 

Fig.  105.  Fig.  106. 


Fig.  105. 
Pulmonary  stenosis  -f  Persistent  ductus  Botalli  ~|-  Defect  in  septum. 
Systolic  murmur  over  Systolic  murmur  at 

pulmonic  area.  the  apex. 

Second  sound  not  ac-  Second  sound  is  accentuated  because  of  dis- 

centuated.  tention  of  heart  with  blood. 

The  pulmonic  circulation  is  chiefly  involved. 

Fig.  106. 

Insufficiency  and  stenosis  of  the  tricuspid  valve  f-  Open  foramen  ovale. 

Systolic  and  diastolic  murmur  over  tricuspid  area.  Open    foramen    ovale 

Second  pulmonic  sound  not  loud  on  account  of  uncombined     with 

changes  in  pulmonic  valves,  stasis,  cyanosis,  another  lesion  ])ro- 

and  venous  pulse.  duces  no  murmur. 

The  systemic  circulation  is  chiefly  involved. 

have  elapsed,  combined  with  attacks  of  asphyxiation  and 
asthmatic  disturbances.  In  not  a  few  cases  the  cyanosis 
is  replaced  by  a  marked  pallor  of  the  skin. 

(3)  Apparent  lack  of  relationship  between  the  shape 
of  the  heart  and  the  other  cardiac  symptoms,  for  example, 
normal  area  of  dulness  with  loud,  rough  musical  mur- 
murs, or  increased  cardiac  dulness  with  heart  murmurs. 


PERICARDITIS  307 

but  a  weak  apex-beat.  Furthermore,  in  making  the 
diagnosis  of  a  congenital  anomaly  in  children,  we  should 
note  the  age  of  the  child,  the  duration  of  the  manifest 
heart  symptoms,  and  all  diseases  which  predispose  to 
endocarditis  (Hochsinger). 

As  simple  as  the  diagnosis  of  congenital  heart  disease 
may  be,  the  diagnosis  of  special  changes  is  difficult  and, 
indeed,  impossible,  for  the  manifold  combinations  of  an 
anomaly  may  mask  the  action  of  a  simultaneously  exist- 
ing second  anomaly.  Bear  in  mind  that  an  abnormally 
weak  second  pulmonic  sound  in  the  presence  of  a  clear 
systolic  murmur  indicates  a  congenital  pulmonic  stenosis  ; 
a  loud  systolic  thrill  in  the  region  of  the  manubrium  of 
the  sternum  and  a  noticeable  and  palpable  closing  of  the 
pulmonic  valves  speak  in  favor  of  a  patulous  ductus 
Botalli.  A  defect  of  the  septum  is  characterized  by  a 
very  loud  systolic  murmur  heard  over  the  whole  heart 
and  unaccompanied  by  a  palpable  thrill  (Hochsinger,  de 
la  Camp). 

Treatment, — This  is  symptomatic.  Avoid  all  injuri- 
ous foctors,  bodily  and  mental  exertion,  exposure  to  cold 
and  infection,  and  forbid  alcoholic  drinks.  Later,  cardiac 
remedies  may  be  necessary. 

PERICARDITIS 

The  most  frequent  forms  of  heart  disease  in  children 
are  pericarditis  and  endocarditis,  which,  not  rarely,  occur 
simultaneously  and  are  caused  by  the  same  injurious 
factors.  As  a  rule  they  occur  secondary  to  other  dis- 
eases, either  due  to  direct  extension  from  a  neighboring 
diseased  organ  (lungs,  pleura,  peritoneum)  or  due  to 
transmission  through  the  blood  of  the  disease  factor  from 
some  other  part  of  the  body.  In  newborn  infants  endo- 
carditis and  pericarditis  are  frequently  the  partial  mani- 
festations of  septic  processes.  In  older  children,  tuber- 
culosis, rheumatic  affections,  certain  forms  of  angina, 
scarlet  fever,  diphtheria,  and  measles  represent  the  com- 
monest etiologic  conditions. 


308  CIRCULATORY  DISEASES 

In  ])ericarditis  a  circumscribed  or  general  inflammation 
of  both  coverings  of  the  heart  exist,  accompanied  by  a 
fibrinous,  serofibrinous,  purulent  or  sanious  (in  septic 
processes),  or  bloody  (in  hemorrhagic  diatheses)  exudate. 
The  clinical  phenomena  often  develop  masked  by  the 
symptoms  of  the  causal  disease.  In  other  cases  the  dis- 
ease picture  is  fulminant  from  the  very  beginning  and 
accompanied  by  chills,  fever  (atypic),  sense  of  fear,  pain 
over  the  cardia,  marked  cardiac  arhythmia,  and  dysj)nea. 
In  dry  pericarditis  (fibrinosa)  a  friction-murmur,  which 
is  exaggerated  on  inspiration,  may  be  heard  or  felt.  In 
exudative  pericarditis  the  anterior  thoracic  wall  bulges, 
the  heart  dulness  is  increased,  and  assumes  the  shape  of 
a  triangle  with  the  base  downward  (reaching  to  the  left 
always  beyond  the  mammillary  line,  to  the  right  fre- 
quently as  far  as  the  parasternal  line).  The  friction-rub 
and  the  apex-beat  which  lie  within  the  area  of  dulness 
gradually  disappear,  and  the  heart  sounds  become  faint. 
The  patient  may  recover  in  from  two  to  three  weeks  with- 
out any  sequelae,  whereas  in  other  cases  the  occurrence  of 
relapses  and  complications  (endocarditis,  pleuritis,  pneu- 
monia, peritonitis)  may  prolong  the  course  over  many 
weeks.  Not  rarely  induration  and  adhesion  to  the  tho- 
racic wall  results  in  dilatation  and  hypertrophy  of  the 
heart.  At  times  pericarditis  leads  to  [)ardlysis  of  the 
heart  and  death. 

The  diagnosis  is  made  from  the  friction-rub,  the  char- 
acteristic shape  of  the  heart,  displacement,  and  finally, 
disappearance  of  the  apex-beat  and  the  increase  of  the 
heart  sounds  in  intensity  upon  rising  and  in  bowing  for- 
ward. A  hectic  fever  and  rapid  decline  point  to  a  puru- 
lent exudate.  Intercostal  systolic  retraction  indicates  ad- 
hesion to  the  thoracic  wall.  In  hydropericardium  the 
friction-rub  is  absent  and  dropsies  exist  elsewhere  in  the 
body. 

Treatment. — To  quiet  the  action  of  the  heart  absolute 
rest  is  needed  (comfortable  and  almost  sitting  posture) ; 
ice-bag  to  the  heart  and  infusion  of  digitalis  internally 
(0.15  to  0.3  gm.  :  120.0)  and  a  mild  and  nutritious  meat- 


ENDOCARDITIS  309 

free  diet.  liater,  to  stimulate  the  secretion  of  sweat  and 
unno,  give  caiJein,  sodium  benzoate,  or  sodium  salicylate 
(0.05  to  0.1  gm.,  twice  daily).  When  the  exudate  be- 
comes so  great  as  to  endanger  life,  resort  to  puncture  and 
aspiration ;  in  case  of  a  purulent  or  serous  effusion,  incise 
and  drain.  [Great  caution  should  be  observed  in  attempts 
to  puncture  the  pericardial  sac.  It  has  been  shown— and 
verified  by  necropsy— that  in  the  majority  of  cases  of 
(^rdiac  enlargement  the  increase  in  size  is  due  to  dilata- 
tion, the  two  layers  of  the  pericardium  are  adherent.  On 
this  account  the  needle  is  easily  thrust  through  the  wall 
of  the  ventricle. — Ed.] 

ENDOCARDITIS 

Infantile  endocarditis  arises  idiopathically  or  asso- 
ciated with  rheumatic  affections  and,  less  rarely,  in 
the  course  of  scarlet  fever,  scarlatinal  nephritis,  and 
chorea.  It  usually  assumes  the  verrucose  form  with  the 
formation  of  fibrinous  growths  on  the  valvular  apparatus 
of  the  left  heart  (in  fetal  endocarditis,  the  right  heart). 
The  ulcerative  form,  with  ulceration  of  the  endothelium 
and  of  the  fibrous  layer  together  with  severe  constitu- 
tional toxic  symptoms,  is  very  rare  in  children. 

Symptoms. — Endocarditis  sets  in,  as  a  rule,  with  a  high 
atypic  fever.  The  general  health  is  considerably  dis- 
turbed, the  heart  much  excited  and  arhythmic,  and  the 
pulse  rate  may  reach  180.  The  respiration  is  markedly 
dyspneic.  In  rare  cases  the  disease  begins  and  runs  a 
course  almost  symptomless,  and  a  systolic  murmur  heard 
loudest  at  the  apex  of  the  heart  may  represent  the  only 
clinical  symptom.  The  changes  in  the  heart  are  most 
variable.  No  murmurs  are  heard  in  endocarditis  of  the 
cardiac  wall,  but  if  deposits  have  formed  on  the  valves 
the  heart  sounds  lose  their  clearnci-s,  and  blowing,  jerky, 
and  even  whistling  murmurs  are  heard.  If  the  mitral 
valve  is  affected  a  loud  systolic  murmur  best  heard  at  the 
apex  exists,  together  with  a  palpable  systolic  thrill,  and 
also  occasionally  a  weakened  apex-beat.     The  heart  is  in- 


310  CIRCULATORY  DISEASES 

creased  in  size  (dilatation  of  the  left  auricle  and  consecu- 
tive excentric  hypeftrophy  of  the  right  ventricle)  and  the 
second  pulmonic  sound  accentuated.  Aifection  of  the 
semilunar  valves  of  the  aorta — which  occurs  very  rarely — 
is  sometimes  characterized  by  a  diastolic  murmur,  together 
with  a  systolic  murmur  at  the  aortic  area.  Endocarditis 
in  children  is  frequently  less  serious  and  is  more  likely  to 
undergo  complete  and  permanent  cure  than  in  the  case  of 
adults.  Thus,  in  favorable  cases,  recovery  may  follow  in 
two  or  three  weeks.  In  a  type  of  endocarditis,  especially 
in  young  children,  the  process  may,  however,  at  the  close 
of  the  acute  stage  run  a  more  incipient  and  subacute 
course,  and  under  the  picture  of  essential  anemia  escape 
detection,  or  the  disease  becomes  chronic,  and  presents  a 
persistiug  systolic  murmur,  slight  cardiac  enlargement, 
and  marked  exaggeration  of  the  second  pulmonic  sound 
(Hochsinger).  In  the  majority  of  older  children  valvu- 
lar defects,  together  with  their  consequent  phenomena, 
remain  behind,  yet  recovery  in  case  of  fully  developed 
heart  disease  is  possible  in  after  years.  The  rare  malig- 
nant and  ulcerative  forms  of  endocarditis  run  a  typhoid- 
like course. 

The  prognosis  is  dubious  in  all  cases,  especially  on  ac- 
count of  the  danger  of  fatal  cerebral  embolism.  [The  ex- 
tent of  inflammatory  changes  in  the  pericardium,  myo- 
cardium, and  endocardium,  the  degree  of  cardiac  dilata- 
tion, and  the  subsequent  effects  of  a  ruptured  compensa- 
tion decide  the  fate  of  the  little  patients. — Ed,] 

Diagnosis. — In  the  presence  of  typic  local  signs  the 
diagnosis  is  easy.  In  other  cases  a  probable  diagnosis  of 
heart  disease  is  made  from  the  cardiac  palpitation, 
arhythmia,  dyspnea,  fever,  and  increased  heart  dulness,  in 
the  absence  of  other  organic  disease.  (For  differential 
diagnosis  between  this  condition  and  Congenital  Heart 
Disease,  see  the  latter — of  importance  is  the  history  of 
previous  articular  pain.) 

Treatment. — Rest  in  bed,  a  non-irritating  diet,  ice-bag, 
and  infusion  of  digitalis  for  the  tension  and  arhythmia  of 
the  pulse.     In  case  of  rheumatic  endocarditis  administer 


FATTY  DEGENERATION  OF  THE  HEART  MUSCLE  311 

sodium  salicylate,  3.0  gm.  :  100.0.  During  convalescence 
pay  strict  attention  to  careful  nursing  and  prescribe 
arsenic  and  iron.  All  exertion  and  excitement  must  be 
avoided  for  a  long  period  of  time. 


MYOCARDITIS 

Jnflanmiation  of  the  heart  muscle  is  either  diffuse  or 
localized  in  foci  due  to  the  deposit  of  inflammatory 
products  in  the  muscular  tissue  (Steffen).  Diffuse  myo- 
carditis with  dilatation  and  weakened  but  clear  heart 
sounds  represent  occasional  complications  or  sequelae  of 
diphtheria.  The  second  form  sets  in  at  the  termination  of 
prolonged  infections,  fevers,  in  tuberculosis,  and  syphilis  ; 
suppuration  of  the  inflammatory  foci  predominates  in 
septic  processes.  The  infection  occurs  by  contiguity  from 
endocarditis  or  pericarditis  or  by  way  of  the  bloo<l  cur- 
rent.    The  anatomic  relations  are  the  same  as  in  adults. 

Symptoms. — The  symptoms  are  usually  severe  and  in- 
definite. Frequently  we  meet  initial  cerebral  symptoms, 
fever,  weakness,  dyspnea,  cardiac  palpitation,  rapid,  irreg- 
ular, and  weak  action  of  the  heart,  pallor,  and  cyanosis. 
Locally  are  observ'ed  :  Dilatation  of  the  ventricle,  muf- 
fled heart  sounds,  and  a  systolic  blowing  murmur  at  the 
apex.  If  healing  does  not  occur  the  gradually  increasing 
cardiac  weakness  leads  to  stupor  and  death,  but  sometimes 
the  latter  may  be  sudden  and  unexpected. 

Diagnosis. — The  severe  symptoms  of  dilatation  of  the 
heart  and  the  weak  arhythmic  cardiac  action  make  the 
diagnosis  probable  but  not  certain  during  life. 

Treatment. — Absolute  rest,  a  strengthening  diet,  .stim- 
ulation, caffein,  or  sodium  benzoate. 

FATTY  DEGENERATION  OF  THE  HEART  MUSCLE 

Fatty  degeneration  of  the  infantile  heart  occurs  only 
partially  in  the  musculature  of  the  right  ventricle,  runs 
an  acute  course  in  infectious  diseases  and  septicemia,  and 
a  chronic  course  in  valvular  defects,  protracted  pneumo- 


312  CIRCULATORY  DISEASES 

nia,  and  pertussis.  The  muscles  are  relaxed,  slightly 
glossy,  covered  with  yellowish  specks,  aud  frequently  with 
extravasated  blood. 

Symptoms. — Weakness,  dyspnea,  cold  extremities, 
weak,  arhythmic  pulse,  aud  lessened  heart  sounds.  With 
increasing  dilatation  and  insufficiency  of  the  valves  weak 
blowing  murmurs  are  heard.  Death  occurs  while  the  ])a- 
tient  is  in  a  stuporous  state  or  it  may  follow  sudden  col- 
lapse. Recovery  is  possible  if  the  disease  develops  only 
to  a  mild  degree. 

Treatment. — The  same  as  in  Myocarditis. 

DISEASES  OF  THE  BLOOD=VESSELS 

Diseases  of  the  arteries  in  children  are  very  rare.  (For 
congenital  regional  (ca[)illary)  anomalies  of  the  blood- 
vessels, or  such  as  develop  during  the  early  period  of 
lif(?,  refer  to  Vascular  Nevi.)  Dilatation  of  the  veins  in 
the  skin  are  often  of  diagnostic  importance  as  symptoms 
of  obstruction  in  cerebral,  intrathoracic,  or  intra-abdomi- 
nal affections  (hydrocephalus,  enlarged  bronchial  or  me- 
diastinal nodes,  etc.). 

LYMPHADENITIS 

Inflammation  of  the  lymph-nodes  is  due  to  infection 
and  usually  follows  regional  disease  of  the  skin  and  mu- 
cous membranes  or  constitutional  conditions,  especially 
tuberculosis.  An  acute  and  a  chronic  form  are  distin- 
guished. Acute  lymphadenitis  consists  of  an  inflammatory 
hyperemia,  while  chronic  lymphadenitis  represents  a  cellu- 
lar hyperplasia  or  tuberculous  infiltration  of  the  lymph- 
nodes. 

Clinical  Symptoms  of  the  Acute  Form. — Enlargement 
of  the  lymph-nodes,  which  are  sensitive  to  pressure, 
swelling  of  the  surrounding  tissues,  and  slight  disturb- 
ance of  the  general  health.  Complete  resolution,  also 
suppuration,  caseation,  and  induration  may  set  in.  Oc- 
casionally acute  lymphadenitis  may  assume  the  picture  of 


LYMPHADENITIS 


313 


Fig.  107. — Chronic  cervical  lymi)l»adonitis.  Ten  year-old  girl.  In- 
dolent swelling  of  the  nodes  of  the  left  .side  of  the  neck  for  three  and  a 
half  years.  No  symptoms  of  tuberculosis  demonstrable.  lodin  treatment 
had  no  noticeable  effect.  Ten  nodes,  which  were  mostly  cji.seatt>d  and 
varying  in  size  from  a  hazel-nut  to  a  i)igeon's  egg,  were  removed  by 
operation.  The  wound  healed  in  seventeen  days.  In  the  course  of  two 
months  glandular  swelling  returned  in  the  region  of  the  scar.  Spontane- 
ous rupture;  healing  followed  i)ainting  with  iodin  and  boric  acid  oint- 
ment. 


an  acute  infectious  disease  with  hi^h  fever,  yet  it  runs  a 
rapid  and  favorable  oour-^e  ("txlandnlar  fever"). 

In  chronic  lymphadenitis  a  gnuliial  .'^welling  of  single 
lymph-nodes  sets  in  unaeoonipanied  l)y  pain  or  disturb- 
ance of  the  general  health.     The   resolution    is  equally 


314  CIRCULATORY  DISEASES 

slow  and  frequently  accompanied  by  suppuration,  case- 
ation, and  induration.  Chronic  lymphadenitis  is  usually 
a  sign  of  syphilis  and  tuberculosis,  and  the  node  is  not 
rarely  the  point  of  origin  of  tuberculosis  in  other  organs. 
Particularly  suspicious  of  tuberculosis  is  the  development 
of  numerous  small  hard  lymph-nodes  in  the  occipital 
region  (micropolyadenitis). 

Treatment. — This  is  sym))tomatic.  Employ  iodin  prep- 
arations. When  tuberculosis  is  suspected  the  glands 
should  be  extirpated  as  soon  as  possible.  [Favorable 
results  are  reported  in  the  treatment  of  tuberculous 
lymph-nodes  by  the  use  of  the  .r-rays.  A  full  diet  and 
out-door  life  is  advisable  in  these  cases. — Ed.]  (For 
further  discussion,  see  Scrofula.) 


DISEASES  OF  THE  RESPIRATORY  ORGANS 

GENERAL  DISCUSSION 

The  upper  air-passages — the  nose.j  mouth,  and  pharynx 
— possess  certain  protective  agencies  in  order  to  preserve 
the  extremely  sensitive  mucous  membrane  of  the  true 
respiratory  organs  from  injurious  influences.  The  mucous 
membrane  of- the  respiratory  portion  of  the  nose  is  sup- 
plied with  ciliated  epithelium  which  retains  bacteria  and 
dust  and  provides  a  bacteria-destroying  secretion.  The 
gland-like  structures  at  the  isthmus  of  the  fauces  and 
roof  of  the  pharynx,  the  palatine  and  pharyngeal  tonsils, 
may  likewise  be  looked  upon  as  a  sort  of  bacteria-filter. 
Thus,  the  inhaled  air  is  filtered  before  its  entrance  into 
the  larynx  and  moistened  and  warmed  by  means  of  the 
rich  blood  supply  to  the  nasal  mucous  membrane.  Dis- 
turbances of  these  protective  agencies  lead,  as  a  rule,  to 
disease  of  the  air-passages.  Even  breathing  through  the 
mouth,  which  offers  but  little  protection  when  the  nose  is 
obstructed,  results  in  irritation  and  inflammatory  catarrh. 
Most  marked,  however,  are  the  disturbances  noted  when 
a  patient  breathes  through  a  tracheal  cannula,  in  which 
case  the  air,  without  any  prophylactic  measures,  passes 
with  all  its  injurious  elements  directly  into  the  trachea 
and  bronchial  tubes.  Hence  we  must  attach  more  im- 
portance to  diseases  of  the  upper  air-passages,  especially 
in  the  case  of  sensitive  children,  than  we  are  wont. 

ACUTE  RHINITIS 

{Coryza;  Snuffles) 

A  catarrhal  condition  of  the  nasal  mucous  membrane, 
accompanied  by  swelling,  redness,  and  increased  secre- 
tion, is  quite  frequent  in  children  and  oven  in  infants. 
It    is   always   due    to   an   infection ;  primarily    through 

315 


316  RESPIRATORY  DISEASES 

various  forms  of  bacteria  and  secondarily  in  various  in- 
fectious diseases  through  the  specific  etiologic  factor.  In 
primary  rhinitis,  thermic,  mechanical,  and  chcmic  irri- 
tants act  as  predisposing  factors. 

The  affection,  which  is  at  first  accompanied  by  a  watery 
mucoid  and,  later,  thick  yellowish-green  secretion  in  large 
quantities,  causes  in  young  children,  especially  in  nurs- 
lings, decided  constitutional  disturbances,  interference  with 
nourishment  and  respiration  (orthopnea,  Henoch),  and 
finally  a  high  fever.  There  is  danger  of  involvement  of 
the  Eustachian  tube  when  the  process  extends  backward 
to  the  nasopharynx.  (For  Acute  Pharyngeal  Angina, 
see  that  condition.)  It  is  of  diagnostic  significance  that 
the  course  of  the  dangerous  primary  nasal  diphtheria  is 
also  accompanied  by  the  symptoms  of  a  febrile  coryza. 

Treatment. — Apply  wet  compresses,  over  which  are 
drawn  thick  woolen  compresses ;  hot  pack  to  the  head  ; 
increase  perspiration  in  order  to  rapidly  abort  the  condi- 
tion. Insufflation  of  boric  acid  powder  by  means  of  a 
paper  cylindric  tube  or  a  powder  insufflator.  (Do  not 
blow  upward.)  Nasal  douche :  By  means  of  a  coffee- 
spoon  or  individual  nasal  glass  pour  into  each  nasal  ori- 
fice a  little  cleansing  fluid  while  the  patient's  head  is  held 
slightly  backward.  As  a  cleansing  fluid  employ  :  Boric 
acid,  sodium  chlorid,  and  glycerin,  of  each,  2.5  gm.  : 
250.0  of  water.  Later,  paint  with  lukewarm  almond 
oil.  In  case  of  orthopnea  instil  1  drop  of  a  1  per  cent, 
cocain  solution,  followed  by  a  douche  of  physiologic  salt 
solution,  or  the  application  of  a  menthol  ointment,  con- 
sisting of  menthol  0.2  gm.,  unguentum  of  boric  acid 
35.0  gm.,  liquid  paraffin  10.0  cc.  If  necessary,  admin- 
ister nourishment  with  a  spoon. 

CHRONIC   RHINITIS   AND  OZENA 

Chronic  rhinitis  develops  gradually  as  a  result  of  fre- 
quent recurrences  of  acute  catarrh  or  on  account  of  cf)n- 
tinued  sojourn  in  a  dusty,  damp,  and  foul  atmosphere. 
It  may  also  occur  as  an  accompaniment  to  heroditary 


CHRONIC  RHLMTIS  AND  OZENA 


317 


318  RESPIRATORY  DISEASES 

syphilis  or  tuberculosis.  Diseases  of  the  pharyngeal 
lymphatics,  adenoid  vegetations,  and  nasal  polyj)i  are 
frequently  concomitant  conditions. 

The  nasal  mucous  membrane  is  considerably  reddened, 
swollen,  and  elevated  in  a  cushion-like  manner;  the 
secretion  is  greenish  yellow  and  purulent.  Nasal  breath- 
ing is  decidedly  interfered  with  and  involvement  of  the 
Eustachian  tube  frequently  causes  difficulty  in  hearing. 
The  stage  of  inflammatory  hyperplasia  is  followed  after 
a  longer  or  shorter  time  by  atrophy  of  the  mucous  mem- 
brane and  of  the  nasal  stroma.  The  pale  mucous  mem- 
brane of  the  dilated  nostrils  is  seen  to  be  coated  with 
grayish-green  scabs.  In  ozena — the  origin  of  which, 
aside  from  association  with  syphilis  and  tuberculosis,  is 
unknown — the  atrophied  mucosa  presents  a  decidedly 
thickened  epithelial  layer  (pavement  instead  of  ciliated 
epithelium),  the  desquamated  cells  of  which  undergoing 
putrefaction  impart  to  the  nose  the  characteristic  ex- 
tremely foul  odor. 

Treatment. — When  possible  remove  the  causal  condi- 
tion. Nasal  douches  ;  introtluction  of  boric  acid  and 
zinc  ointment  tampons.  In  ozena,  regular  and  conscien- 
tious spraying  with  katharol  and,  finally,  employ  the 
yeast-cure. 

ACUTE  LARYNGITIS  AND  PSEUDOCROUP 

Catarrhal  inflammation  of  the  laryngeal  mucous  mem- 
brane arises  from  the  same  causes  as  acute  rhinitis  (ex- 
posure to  cold,  specific  or  non-specific  infection),  but 
frequently  occurs  only  as  a  sequel  to  a  catarrhal  condition 
of  the  nasopharyngeal  space. 

Symptoms. — The  disease  begins  with  manifestations  of 
catarrhal  irritation  of  the  nose,  conjunctiva,  and  witii  a 
tickling,  burning  sensation  in  the  throat  and  a  great  in- 
crease in  temperature.  A  short,  dry  cough  and  slight 
hoarseness  soon  set  in.  Laryngoscopic  examination  shows 
the  mucous  membrane  of  the  larynx  and  adjacent  trachea 
to.be  reddened  and  swollen.     In  severe  cases  the  sub- 


ACUTE  LARYNGITIS  AND  PSEUDOCROUP      319 

mucosa  of  the  upper  portion  of  the  larynx  may  also  be 
involved  (genuine  croup  of  measles),  likewise  the  sub- 
chordal  region  (pseudocroup).  Narrowing  of  the  lumen 
of  the  larynx  and  the  collection  of  secretion  causes  sten- 
otic disturbances.  The  latter  occur  in  pseudocroup  in 
attacks  and  only  during  sleep.  The  child,  which  for- 
merly showed  only  mild  catarrhal  symptoms,  awakens 
suddenly  during  the  night  with  a  high  fever,  a  barking 
cough,  and  hoarseness  (which  is  never  so  severe  as  to 
result  in  aphonia),  and  presents  all  of  the  signs  of  as- 
phyxiation, which  for  several  minutes  appear  to  threaten 
life.  The  attack,  however,  soon  passes  over  and  the 
child  rapidly  recovers ;  the  attack  may  repeat  itself 
during  the  same  night  or  during  the  following  night. 
Only  rarely  does  death  follow  asphyxiation  during  an 
attack. 

The  explanation  of  the  rapid  and  frequent  development 
of  threatening  laryngeal  stenosis  in  children  is  found  in 
the  jx'culiar  anatomic  construction  of  the  child's  larynx. 
The  latter  is  of  a  very  delicate  and  yielding  structure, 
not  only  absolutely — but  also  relatively — smaller  than  in 
the  adult,  especially  in  the  sagittal  diameter.  The  glottis 
is  short,  the  intemrytenoid  space  is  especially  small,  and  is 
furthermore  lined  with  a  mucous  membrane  rich  in  blood- 
vessels and  glands,  the  swelling  of  which  may  easily 
cause  closure  of  the  respiratory  glottis.  Such  a  swelling, 
because  of  the  sensitiveness  to  irritation  of  the  infantile 
laryngeal  mucosa,  occurs  very  frequently.  It  may  be 
assumed,  especially  in  pseudocroup,  that  the  collection  of 
the  large  quantities  of  tough  secretion  during  sleep  excites 
a  reflex  glottic  spasm  with  the  sudden  development  of 
stenosis. 

The  differential  diagnosis  offers  difficulty  not  only  dur- 
ing the  interval,  but  also  in  an  attack  (see  the  following 
subject),  particularly  because  in  highly  excitable  children 
it  is  usually  impossible  to  make  a  laryngoscoj)ic  examina- 
tion. Such  an  examination  tends  only  to  increase  the 
stenosis.  Inspection  of  the  pharynx  offers  the  same 
picture  in  pseudocroup  as  in  laryngeal  diphtheria  (without 


320  RESPIRATORY  DISEASES 

Fig.  109. — Multiple  papilloma  of  the  larynx.  Girl  two  and  a  half 
years  old.  Since  the  first  year  of  life  iucreasinj;  hoarseues-s,  otherwise 
healthy.  Treatment  for  the  suspected  laijMiji;itis  was  inelTectual.  At 
the  beginning  of  the  second  year  adenotomy  was  performed,  but  without 
iufluence  upon  the  condition.  In  a  short  time  the  hoarseness  increased 
to  complete  aphonia.  Attacks  of  asphyxiation  occurred  at  times.  Lar- 
yngo-scopic  examination  was  frustrated  by  the  patient's  restlessness  and 
by  tlie  rapid  development  of  stenosis  which  the  operation  excited.  In- 
tubation was  then  performed.  The  tube  was  easily  .introduced,  but  was 
soon  coughed  out.  This  was  followed  by  considerable  relief,  the  cyanosis 
disappeared,  and  a  certain  amount  of  phonation  w;vs  possible.  The 
child  recovered  and  treatment  ceased.  Four  weeks  later  death  occurred 
suddenly  at  night  in  an  attack  of  sulTocation.  Necropsy  :  The  superior 
portion  of  the  larynx  was  rilled  with  a  white  ]iapillomatous  mass.  A 
narrow  central  canal,  which  could  have  been  occluded  by  a  floating  por- 
tion of  a  growth  which  was  attached  to  the  median  portion  of  the 
larynx. 

pharyngeal  deposits),  namely,  redjiess  and  swelling  of  the 
mucous  membrane  and  thickening  of  the  ulcerated  epiglot- 
tis. We  are,  therefore,  dependent  upon  the  history  in 
making  this  distinction  Avhich  is  of  so  much  imjwrtance 
therapeutically.  In  favor  of  diphtheria  are  gradually 
but  steadily  developing  catarrhal  symptoms  and  stenosis, 
together  with  increase  of  hoarseness,  until  complete 
aphonia  sets  in.  The  patient  recovers  only  partially 
after  the  attack,  continues  to  be  dyspneic,  and  its  restless 
sleep  is  rej)eatedly  disturbed  by  fresh  attacks  of  asphyxia- 
tion. In  favor  of  pseudocroup  are  tlie  sudden  and  unex- 
pected development  of  severe  symptoms,  a  clearer  tone  to 
the  cough,  and  the  absence  of  aphonia.  After  the  attack 
the  patient  u.sually  falls  asleep  and  only  the  symptoms  of 
a  severe  laryngotracheal  catarrh  ])ersist. 

Treatment. — In  simple  laryngitis,  rest  in  bed,  Priess- 
nitz's  compresses,  and  hot  drinks  to  stimulate  sweating. 
For  phlegmonous  swelling,  mustard  and  water  and  hot 
pack  to  encourage  perspiration.  During  the  attack  of 
pseudt>croup  give  hot  drinks,  apply  a  hot  sponge  to  the 
neck,  administer  an  emetic,  and  in  case  of  a  high-grade 
stenosis,  resort  to  intubation.  [During  an  attack  of  acute 
laryngitis,  sedatives,  such  as  sodium  bromid  or  cam])hor- 
ated  tincture  of  opium,  arc  of  great  service  in  quieting  the 
child,  diminishing  the  paroxysms  of  cough,  and  lessening 
the  local  congestion. — Ed.] 


Fig.  U)9. 


21 


■d2i 


322  RESPIRATORY  DISEASES 

PAPILLOMA  OF  THE  LARYNX 

Papilloma  represents  the  commonest  tumor  of  the 
larynx  in  childhood  (von  Rauchfuss).  It  may  be  congen- 
ital or  follow  continued  inflammatory  affections  of  the 
larynx.  According  to  its  location,  size,  and  number  it 
may  gradually  produce  a  stenosis  or  a  valve-like  closure 
of  the  larynx.  Permanent  hoarseness  arises  unaccom- 
panied by  fever.  The  prognosis  is,  as  a  rule,  unfavorable. 
As  a  therapeutic  measure  resort  may  be  had  to  intubation 
with  a  heavy  metallic  tube  (or  curetment  with  O'Dwyer's 
fenestrated  tube).  A  laryngotomy  may  be  performed,  the 
growth  excised,  and  a  tracheotomy  tube  inserted. 

FOREIGN  BODIES  IN  THE  AIR-PASSAGES 

The  entrance  of  a  foreign  body  into  the  air-passages 
of  children  is  a  very  frequent  and  nearly  always  fatal 
occurrence.  It  may  be  aspirated  by  way  of  the  mouth 
through  an  involuntary  violent  inspiration  in  laughing, 
coughing,  and  fright.  The  body  then  causes  a  mechan- 
ical obstruction  to  breathing,  either  on  account  of  its  size 
or  on  account  of  its  sharp  edges  ;  a  stenosis  indirectly,  by 
piercing  the  mucous  membrane  and  exciting  a  laryngeal 
edema.  If  the  body  enters  a  bronchial  tube  and  cannot 
be  removed  by  means  of  the  bronchoscope,  it  leads  to 
consecutive  complications  like  bronchitis,  pneumonia, 
atelectasis,  abscess,  gangrene,  and,  finally,  death. 

Diagnosis. — Of  diagnostic  significance  is  the  sudden  de- 
velopment of  choking  and  dyspnea  in  a  child  previously 
healthy.  In  the  course  of  time  frequently  re})eated  at- 
tacks of  pneumonia  occur  at  the  same  site,  and  soon 
symptoms  arise  of  cavity  formation,  empyema,  and  pneu- 
mothorax. Characteristic  is  the  rapid  change  of  the 
phenomena  (Fronz,  Hecker).  Secure  a  skiagram  of  the 
larynx  and  bronchus. 

The  treatment  is  operative.     After  removal  of  the  for- 
eign body  the  most  serious  pulmonary   processes,  even 
gangrene,  undergo  resolution  and  recovery. 
STRUMA  (see  page  138). 


NERVOUS  OR  BRONCHIAL  ASTHMA  323 


HYPERPLASIA  OF  THE  THYMUS  GLAND 

Extraordinary  increase  in  size  of  the  thymus  gland, 
especially  in  case  of  true  tumors  of  that  organ  (leukemia 
and  lymphosarcoma),  may  lead  to  chronic  stenosis  of  the 
trachea  or  bronchus  {stridor  thymicus,  Hochsinger).  Fur- 
thermore, hyperplasia  of  the  thymus  tends  to  cause 
laryngospasm,  and  is  an  important  concomitant  symptom 
of  the  constitutional  anomaly  called  "  status  lymphaticus  " 
(Paltauf,  Escherich),  which  may  lead  to  sudden  death. 
Percussion  reveals  at  both  sides  of  the  manubrium — 
especially  to  the  left — an  increased  amount  of  dulness, 
which  passes  downward  into  the  cardiac  dulness. 

The  diagnosis  is  verified  by  skiagraphy. 

The  treatment  consists  in  trying  organotherapy  (tablets 
of  thymus-gland  substance)  or  displacement  of  the  gland 
by  operation. 

NERVOUS  OR  BRONCHIAL  ASTHMA 

A  pure  essential  bronchial  asthma,  which  is  a  reflex 
neurosis  accompanied  by  spasmodic  attacks  of  dyspnea 
(spastic  contracture  of  the  bronchial  musculature),  occurs 
with  the  well-known  symptoms  in  children  of  all  ages. 
Hereditary  influence  plays  an  importjint  role.  It  is  fre- 
quently also  caused  by  nasopharyngeal  disease  (Baginsky), 
especially  adenoid  growths  (nasal  asthma,  the  usual  ex- 
citing cause  is  an  acute  catarrh)  or  indigestion  (dys- 
pej)tic  asthma).  During  the  first  two  years  of  life 
asthma  (cardiac)  is  frequently  at  first  superimposed 
upon  a  congenital  defect  of  the  heart.  Eczematous 
patients  are  not  rarely  subject  in  later  life  to  asthma 
(Feer). 

Treatment. — As  prophylaxis  avoid  exposure  to  cold  and 
judicious  hardening  of  the  body.  Change  of  scene  ;  so- 
journ at  the  soa  or  at  mountain  resorts  of  moderate 
height.  Operative  procedures  for  nasal  asthma  ;  emetics 
for  dyspeptic  asthma.  During  and  after  the  attack  give 
every  two  hours  a  coffeespoonful  or  a  ciiild's  spoonful  of 


324  RESPIRATORY  DISEASES 

sodium  bicarbonate  or  potassium  ioditl,  of  each  2.0  gm. 
to  100.0  cc.  (Neumaun).  Hot  pack  to  stimulate  sweat- 
ing. Vapor  inhalations  ;  emetics.  During  the  intervals 
give  arsenic. 

ACUTE  TRACHEITIS  AND  BRONCHITIS 

Acute  tracheitis  and  bronchitis  arise  from  the  same 
causes  as  acute  laryngitis,  and  frequently  at  the  termina- 
tion of  a  catarrhal  disease  of  the  upper  air-passages. 

Morbid  Anatomy. — The  mucous  membrane  of  the  tra- 
chea and  the  large  bronchial  tubes  is  reddened,  swollen, 
relaxed,  and  after  long  duration  of  the  disease  becomes 
pale  gray  and  atrophied.  The  secretion  covering  the 
mucous  membrane  is  generally  tenacious,  glossy,  and 
contains  air-bubbles,  but  at  a  later  stage  it  becomes 
thicker,  mucopurulent,  yellow,  or  greenish  yellow. 

Symptoms. — The  disease  begins  with  a  dry,  jwiinful, 
and  spasmodic  cough,  increased  respiration  rate,  fever, 
loss  of  sjHrit  and  appetite.  Young  children  usually 
swallow  the  excretion;  the  expectoration  of  older  chil- 
dren shows  the  above-described  characteristics.  Palpa- 
tion reveals  nlles  over  the  whole  thorax.  Percussion  is 
negative.  On  auscultation  at  the  beginning,  when  the 
mucous  membrane  is  simply  swollen,  we  hear  dry  rales, 
but  as  the  serous  secretion  increases,  moist  large  and 
small  vesicular  rales  are  heard.  The  intensity  of  the 
tone  of  the  rales  depends  upon  the  distance  between  the 
disease  focus  and  the  l)ody  surface.  The  respiratory 
murmur  is  vesicular,  accentuated,  and  sometimes  inter- 
rupted by  the  noise  of  the  rales.  In  catarrh  of  the 
bronchi,  both  lungs,  es|)ecially  the  lower  lobes,  are  in- 
volved. After  several  days'  duration  the  fever  falls  by 
lysis,  all  symptoms  lessen  in  severity,  and  the  cough  be- 
comes looser  and  disappears  gradually  in  one  or  two 
weeks.  In  weak  children  living  in  an  unhealthy  atmo- 
sphere and  in  neglect  of  the  acute  symptoms  the  affection 
becomes  chronic  and  lays  the  foundation  for  tuberculosis 
of   the   bronchial    nodes.     The   prognosis   is,  therefore. 


ACUTE  TRACHEITIS  AND  BRONCHITIS         325 

dubious  under  the  conditions  mentioned.     (For  differen- 
tiation from  Pertussis,  see  that  disease.) 

Treatment. — Attempt  to  abort  the  disease  during  the 
development  by  hot  packs  or  baths,  in  order  to  increase 
perspiration.  Provide  fresh  air,  keep  the  bo<ly  warm, 
and  rest  in  bed  in  case  of  fever.  Priessnitz's  compresses  ; 
hot  drinks  to  excite  expectoration  and  jwrspiration. 
Moisten  the  inhaled  air  by  means  of  an  inlialer  or  croup 


Fig.  110. — Vapor  apparatus  for  moi.steiiing  the  air  to  be  inhaled  iu 
diseases  of  the  respiratory  tract.  The  kettle  is  filled  with  1  liter  [1  qt.] 
of  boiling  water.  Camomile  and  other  preparations  are  jilaced  in  the 
upper  portion  of  the  ai>iiaratiis.  The  current  of  steam  which  travels  for 
about  i|  meters  [4J  ft.]  is  directed  against  .the  face  of  the  patient.  To 
obtain  a  more  pronounced  action  (especially  in  croup  or  pseudocroup)  a 
primitive  steam  room  may  be  arranged  by  spreading  linen  sheets  over 
the  bed. 


kettles.  Internally  give  a  coffeespoonful  of  the  infusion 
of  ipecacuanha,  0.3  gni.  to  120.0-150.0  cc,  every  two 
hours.  To  this  may  be  added  the  extract  of  belladonna, 
codein,  or  aqua  amygdalae  amarae,  in  order  to  lessen  the 
irritation  of  the  cough,  and  liquor  amm.  anis.  or  (according 
to  Fischl)  potassium  iodid,  0.3  to  1 .5  gm.,  to  stimulate 
ex|X'ctoration.  In  very  young  children  administer  a 
child's  spoonful,  every  two  hours,  of  syrup  of  ipecacuanha 
with  syrup  of  senega  or  althea. 


326  RESPIRATORY  DISEASES 

CHRONIC  BRONCHITIS 

In  chronic  bronchitis  the  persistent  cough  is  looser  and 
of  a  catarrhal  character ;  the  secretion  is  sometimes  more 
profuse,  more  frequently,  however,  it  is  less  in  quantity, 
while  the  sputum  is  grayish  yellow  and  appears  in  lumps. 
On  palpation  mucous  rales  are  felt,  and  on  auscultation 
vesicular  breathing  and  coarse  rales  are  heard.  The  res- 
piration rate  is  not  increased.  The  aifection,  provided  it 
is  not  of  a  tuberculous  nature,  is  not  accompanied  by 
fever  or  marked  disturbances  of  the  general  health, 
although  in  some  cases  asthmatic  symptoms  arise.  (With 
reference  to  the  development  of  Bronchiectasis,  see  that 
condition.) 

Treatment. — Provide  as  hygienic  a  life  as  possible.  So- 
journ at  the  sea  or  in  the  mountains.  A  non-irritating 
and,  preferably,  vegetable  diet.  If  the  secretion  is  pro- 
fuse, inhale  oil  of  turpentine ;  if  it  is  scanty,  inhale  salt 
water.  Internally  give  potassium  iodid  and  alkaline  and 
muriatic  waters. 

CAPILLARY  BRONCHITIS 

If  the  inflammatory  process  spreads  from  the  large  and 
moderate-sized  bronchial  tubes  to  the  smaller  and  minute 
bronchi,  we  have  a  capillary  bronchitis,  the  most  danger- 
ous disease  of  the  respiratory  passages.  When  this 
region  is  once  involved,  the  process  extends  rapidly  to  a 
large  section  of  the  bronchial  tree. 

Morbid  Anatomy. — The  mucous  membrane  of  the  bron- 
chial tubes — even  in  the  smallest  branches — is  intensely 
red,  swollen,  and  covered  with  a  tenacious,  glossy,  and 
(later)  mucopurulent  secretion.  The  bronchioles  are  in 
some  areas  completely  obstructed  by  the  swelling  and 
secretion,  and  not  rarely  the  associated  alveolar  portion 
collapses  after  the  absorption  of  the  air  and  becomes  ate- 
lectatic. The  atelectatic  lobules  are  bluish  red,  relaxed, 
hypereniic,  and  diminished  in  volume.  On  section, 
slight  pressure  will  cause  a  large  amount  of  pus  to  oo7.e 
from  the  medium-  and  smallest-sized  bronchial  tubules. 


CAPILLARY  BRONCHITIS.  327 

The  disease  picture  is  a  very  severe  one.  The  inflam- 
matory swelling  of  the  mucous  membrane  tends  to  cause 
a  dangerous  stenosis  in  the  infantile  bronchi,  for  the  nar- 
row bronchial  lumen  easily  becomes  obstructed  by  the 
tenacious  secretion.  The  direct  result  is  defective  aera- 
tion of  the  lungs,  that  is,  insufficient  entrance  of  oxygen 
and  discharge  of  carbon  dioxid.  The  indirect  results 
are  an  increased  activity  and  a  decrease  of  the  heart's 
ability  to  work. 

Symptoms. — Clinically  these  changes  make  a  distinct 
impression.  When  very  extensive  they  begin  with  high 
fever,  dyspnea,  and  cyanosis.  The  respiration  is  super- 
ficial, irregular,  and  rapid ;  in  the  case  of  nursing  infants 
it  is  increased  to  60  and  100  per  minute.  On  inspiration 
the  ribs  are  retracted.  The  alse  nasi  move  with  the  res- 
piration. The  expiration  is  prolonged,  accentuated,  and 
sighing.  The  cough  is  frequent,  short,  painful,  and 
therefore  suppressed  as  much  as  possible.  Great  rest- 
lessness and  symptoms  of  indigestion.  The  skin  is  j)ale 
and  the  mucous  membrane  slightly  cyanosed.  The  pulse 
is  small  and  has  a  rate  of  120  to  180.  The  temperature 
averages  between  39°  and  39.5°  C.  [102.2°  and  102.7°  F.l, 
it  is  irregular,  remittent,  and  frequently  increases  with 
extension  of  the  process.  Examination  of  the  lungs 
gives  the  same  results  in  capillary  bronchitis  as  in  acute 
bronchitis,  only  we  find  in  several  areas,  esj>ecially  at 
the  bases  posteriorly,  fine  vesicular  rales  which  frequently 
drown  the  puerile  vesicular  breathing,  and  are  only  dis- 
tinguished from  the  crepitant  rales  of  pneumonia  by  the 
fact  that  they  are  also  audible  on  expiration.  The  res- 
piratory murmur  is  often  completely  absent  over  por- 
tions of  the  lungs  where  the  bronchi  are  obstructed. 
With  gradual  disappearance  of  all  symptoms  the  patient 
may  completely  recover  in  the  course  of  a  week.  It  fre- 
quently causes  death  (especially  in  rachitic  children)  or  it 
may  lead  to  atelectasis  and  j)neumonia. 

The  prognosis  is  always  doubtful,  especially  in  weak 
and  rachitic  children  or  in  those  predisposed  to  tubercu- 
losis.    It  is  unfavorable  when  the  process  extends  sud- 


328  RESPIRATORY  DISEASES 

denly  to  the  whole  bronchial  tree.  In  many  instances 
tlie  inflammation  involves  the  puhnonary  tissue  also. 

Diagnosis. — The  passing  of"  a  bronchitis  into  the  capil- 
lary type  is  marked  by  the  sudden  development  of  high 
fever,  increased  irritation  of  the  cough,  shortened  respi- 
rations, and  a  sighing  expiration.  After  the  preliminary 
symptoms  only  a  few  febrile  catarrhal  manifestations  exist. 
Capillary  bronchitis  is  distinguished  from  pneumonia  by 
the  absence  of  bronchial  breathing,  bronchophony,  and 
dulness.  The  differentiation  may,  however,  be  impossible 
wiien  the  pneumonia  is  not  extensive  and  it  is  impossible 
to  determine  the  presence  of  pneumonic  consolidation  by 
physical  signs. 

The  treatment  is  that  of  bronchopneumonia. 

BRONCHOPNEUMONIA 

{Lobviar  Pneumonia.     The  Pneumonia  of  Children) 

If  the  inflammatory  process  spreads  to  the  pulmonary 
tissue  the  alveoli  become  filled  with  inflammatory  prod- 
ucts (serous  or  serofibrinous  exudate,  pus-corj)uscles,  and 
desquamated  alveolar  epithelium).  The  involved  portion 
of  the  lungs  is  thus  congested  and  unable  to  perform  its 
function,  and  we  have  the  condition  known  as  broncho- 
pneumonia. The  inflammation  travels  longitudinally 
along  the  bronchial  tubes  to  the  alveoli  or  it  penetrates 
the  bronchial  wall  and  attacks  the  peribronchial  tissue. 
In  both  cases  we  note  circimiscribed,  either  lobular  or 
peribronchial  foci,  which  coalesce  and,  enlarging,  finally 
involve  a  whole  lobe,  the  so-called  "  pseudolobar  form." 

This  type  of  pulmonary  disease  is  characterized  by  the 
fact  that  it  originates  in  a  disease  of  the  bronchial  tree. 
The  direct  cause  of  the  condition  may  be  of  a  specific  or 
non-specific  nature.  To  the  first  class  belong  the  micro- 
organisms of  measles,  whooping-cough,  dij)htheria,  and 
influenza,  and  to  the  second  class  the  various  |)iieumo- 
coccic  bacteria  (bacillus  of  Friedliinder,  Friiidvel-Weich- 
selbaum  diplococcus)  and  pus  cocci.  Occasionally  the 
pneumonia  follows  the  aspiration  of  particles  of  food  or 


BRONCHOPNEUMONIA  329 

niiicu.s  by  children  when  in  a  stuj)oroiis  state  or  when  a 
tracheotomy  has  been  pertbriued — -foreign-body  or  aspira- 
tion pneumonia. 

Morbid  Anatolny. — The  diseased  lung  tissue  is  already 
recognizable  raacroscopically  by  its  increased  volume, dark 
discoloration,  and  its  hard,  nodular  consistency.  The 
pleura  in  the  region  of  the  disease  process  is  at  times 
covered  with  a  thin  fibrinous  deposit  and  isolated  hemor- 
rhages. Section  shows  a  varied  picture  ;  side  by  side 
are  seen  pale  normal  air-containing  lung  tissue  and 
brownish-red,  prominent,  airless,  and  dense  inflammatory 
foci  of  varying  size,  the  centers  of  which  are  sometimes 
faded  ;  aside  from  which  we  always  note  bluish-red,  soft, 
airless,  and  somewhat  retracted  atelectatic  areas.  The 
inflamed  foci  show  a  smooth  surface  which — when  con- 
siderable fibrin  exists — is  granulated.  Pus  can  be 
scpieezed  outof  tlie  inflamed  bronchi  and  a  turbid  yellow- 
ish fluid  from  the  diseased  portions  of  the  lungs.  The 
air-content  is  decidedly  diminished.  In  peribronchitis 
the  bronchial  wall  is  thickened.  The  pulmonary  cortex 
is  frequently  emphysematous  and  atelectatic.  Prolonga- 
tion of  the  disease  leads  to  cylindric  ectasia  of  the  small- 
est bronchi,  hyperplasia  of  the  bronchial  nodes,  fatty 
degeneration  of  the  heart  muscle,  and  dilatation  of  the 
right  heart.  Microscopically  we  find  round-cell  infil- 
tration and  ])ronounced  congestion  of  the  alveolar  borders, 
and,  later,  of  the  peribronchial  tissue  also.  The  alveoli 
are  filled  with  a  mass  of  cells  which  have  undergone 
j)artial  fatty  degeneration  and  an  inflammatory  exudate, 
which  sometimes  contains  but  a  small  amount  of  fibrin 
and  at  other  times  a  large  (juantity.  This  |)eculiarity  of 
the  bronchopneumonic  exudate,  which  is  only  mrely  of  a 
purely  catarrhal  nature,  is  characteristic  of  the  pneumonia 
of  children,  and  is  also  noticeable  in  the  clinical  course 
of  the  disease.  Noteworthy  is  the  frequent  occurrence 
of  giant  cells  in  tiie  pneumonic  infiltrated  alveoli  in 
diphtheria  and  measles.  (Concerning  characteristic 
changes  in  the  Pneumonia  of  Whooping-cough,  see  that 
disease.) 


330  RESPIRATORY  DISEASES 

PLATE  34 

Fig.  1.  Confluent  Bronchopneumonia  in  a  Child  Two  Years  Old.— 

The  iuflamiuation  has  existed  for  several  weeks.  Enhirged  52  times. 
The  microscopic  picture  of  a  fully  cousolidated  puluiouary  lobe  offers  a 
uuiform  appearance.  The  alveoli  are  filled  with  an  exudate  which  con- 
sists of  fibrin  (retracted  on  account  of  the  }iardeniugpro<;ess),  degenerated 
alveolar  epithelium  which  stains  with  difficulty,  and  a  few  leukocytes, 
while  in  some  areas  only  pus-corpuscles  are  present.  1.  Exudate  com- 
posed of  fibrin,  degenerated  epithelium,  and  a  few  leukocytes.  2.  Puru- 
lent exudate.     3.  Alveolar  borders  showing  round-cell  infiltration. 

Fig.  2.  Bronchitis  and  Beginning  Bronchopneumonia  in  a  Child  One 
Year  Old.— Died  of  enteritis.  Enlarged  52  times.  The  picture  shows 
the  extension  of  the  bronchopneumonia  from  a  bronchitis.  The  inflam- 
matory process,  which  was  primarily  confined  to  the  bronchial  mucous 
membrane,  has  penetrated  the  whole  bronchial  wall  and  caused  infiltra- 
tion of  the  peribronchial  tissue.  The  manner  in  which  two  peribronchitic 
foci  have  become  confluent  may  be  seen.  The  freshly  infiltrated  tissue  is 
hyperemic.  1.  Lumen  of  a  bronchus.  2.  Desquamated  bronchial  epi- 
thelium. 3.  Catarrhal  bronchitic  exudate.  4.  Bronchitic  exudate  with 
a  large  amount  of  exfoliated  bronchial  epithelium.  5.  Beginning  broncho- 
pneumonic  exudate.  6.  Confluent  infiltrate.  7.  Dilated  blood-vessels. 
8.  Normal  lung  tissue. 

Symptoms.  —  Bronchopneumonia  can  often  be  distin- 
guished clinically  from  capillary  bronchitis  only  by  the 
changes  in  percussion.  As  soon  as  the  congested  foci 
have,  through  confluence,  reached  a  certain  extent,  pro- 
vided they  are  not  too  deeply  seated,  they  may  most 
frequently  be  demonstrated  by  percussion  in  the  region 
of  the  axilla  and  parallel  to  the  spine.  Auscultation  dis- 
closes, aside  from  loud  catarrhal  and  at  times  bronchial 
murmurs,  fine  vesicular  rales,  and,  if  the  afferent  bron- 
chial tubes  are  not  obstructed,  bronchial  breathing  and 
bronchophony.  Vocal  fremitus  is  increased  vvlicn  the 
process  is  extensive.  The  course  of  the  disease  and  the 
general  and  local  symptoms  vary  from  ca.se  to  case,  ac- 
cording to  the  extent  of  the  anatomic  process  and  the 
character  of  the  exudate.  When  large  pneumonic  areas 
become  confluent  and  a  cellular  and  fibrinous  exudate 
occurs,  the  symptoms  resemble  tho.se  of  fibrinous  and 
croupous  pneumonia,  so  that  it  is  impossible  to  distinguish 
between  these  two  forms.  On  account  of  frequent  relap.ses 
the  intensity  of  the  symptoms  may  also  vary  consider- 
ably in  individual  cases. 

The  disease  frequently  runs  a  course  of  many  weeks, 


Iab.3^. 


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12        3 


Iig.l. 


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/->- 


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1-^.-- 

J*:- 


4  — 


Eig.Ji 


BRONCHOPNEUMONIA  331 

although  iu  favorable  cases  it  may  end  in  one  or  two. 
Resolution  sets  in,  with  the  gradual  disappearance  of  the 
dulness,  fall  of  the  fever  by  lysis,  and  improvement  of  all 
remaining  symptoms  and  the  general  condition.  Death 
may  follow  from  weakness  or  from  carbonic-acid-poison- 
ing. Lobular  pneumonia  passes  into  the  chronic  form, 
not  rarely  by  caseation  of  the  alveolar  contents  or  inflam- 
mation of  the  interstitial  tissue.  It  is  quite  often  pri- 
marily of  a  tuberculous  character  or  it  terminates  in  a 
miliary  tuberculosis.  Frequent  complications  are  pleu- 
risy, gastritis,  and  otitis  media. 

Diagnosis. — The  lack  of  physical  signs  of  changes  in 
the  pulmonary  parenchyma  at  the  beginning  and  the  prev- 
alence of  some  causal  disease  frequently  leads  to  a 
mistaken  diagnosis.     In  favor  of  bronchopneumonia  are  : 

Sudden  and  marked  rise  in  temperature  during  the 
course  of  a  bronchitis  or  the  persistence  of  a  high  fever 
beyond  the  usual  febrile  period  of  a  causal  disease 
(measles). 

Lessening  and  painfulness  of  a  formerly  vigorous 
cough.  Difficult  and  rapid  breathing.  Activity  of  the 
accsssory  muscles  of  respiration.  Movement  of  the  alae 
nasi  in  breathing. 

Physical  signs  of  pulmonary  consolidation. 

Occurrence  on  both  sides.  In  favorable  cases  resolu- 
tion is  gradual,  the  fever  falls  by  lysis,  without  regard  to 
critical  days  and  slow  convalescence. 

In  atelectasis  the  percussion-note  is  not  so  dull  and  is 
usually  accompanied  by  a  tympanitic  note.  Bronchial 
breathing  and  bronchophony  are  absent,  only  subcrepi- 
tant  inspiratory  rSles  are  audible,  which  disap|)ear  with 
deej)  respiration.  In  croujious  pneumonia  the  disease  is 
a  primary  condition  which  begins  on  one  side;  the 
catarrhal  rales  are  absent,  the  consolidation  involves  part 
of  a  lobe,  the  fever  is  higher  and  ends  nearly  always  by 
crisis.  In  pleurisy  the  dulness  is  more  resistant,  of  a 
characteristic  form  and  extent.  The  vocal  fremitus  is 
lessened.  The  anamnesis  gives  valuable  information  in 
caseating  tuberculous  pneumonia.     The  loss  of  strength 


332  RESPIRATORY  DISEASES 

is  disproportionately  rapid.  Tiie  course  is  susj)iciously 
long.  Symptoms  of  cavity  formation  and  the  develop- 
ment of  tuberculous  affections  in  other  organs  frequently 
arise.  Tiie  prognosis  in  weak,  rachitic,  or  scrofulous 
children  is  always  doubtful.  The  disease  is  far  more 
dangerous  than  croupous  pneumonia  and  is  more  fre- 
quently followed  by  j)ermanent  changes  in  the  respiratory 
tract. 

Treatment. — Treat  the  original  causal  disease.  Observ- 
ance of  general  dietetic  and  hygienic  principles  as  in  acute 
bronchitis.  Frequent  change  of  position  in  the  be  J  to 
avoid  hypostasis  (infants  should  be  carried  about  at  inter- 
vals). At  the  beginning  of  the  disease  relieve  the  bronchi 
by  an  emetic.  Give  for  this  j)urpose  powdered  ipecac, 
0.5  to  2.5  gm,,  with  syrtip  of  althea,  40.0  cc,  of  which 
a  coffeespoonful  is  given  every  ten  minutes  until  effect  is 
produced.  Later,  for  thermic  stimulation  of  the  nerves; 
to  combat  the  fever,  to  deepen  the  respiration,  and  to  ex- 
cite ex|)ectoration,  resort  to  hvdropat hie  measures  :  Baths 
at  a  temperature  of  25°  to  35°  C.  [77°-95°  F.],  varying 
with  the  fever  and  the  patient's  strength,  followed  by 
short  cold  douches.  (If  influenza,  pertussis,  or  rachitis 
are  simultaneously  present,  the  bo<ly  heat  must  not  be 
lowered  too  vigorously.)  In  case  of  subnormal  tempera- 
ture or  difficult  breathing  on  account  of  carbonic-oxid  in- 
toxication, subject  the  occiput  and  neck  to  a  stream  of 
water  as  cold  as  possible.  As  many  as  ten  streams  fol- 
lowing each  other  may  be  applied,  at  intervals  of  from 
ten  to  twenty  seconds,  and  each  stream  should  meas- 
ure about  1  cm.  [.4  in.J  in  diameter  (Jurgensen).  In 
place  of  baths  employ  cold  and  moist  packing,  leaving 
the  head,  arras,  and  legs  exposed  ;  to  increase  the  radia- 
tion of  heat  renew  the  pack  every  ten  minutes.  If 
the  condition  becomes  worse  and  the  surface  of  the 
body  cold,  use  mustard  pack.  The  internal  medication 
consists  of  enemata  of  quinin  (0.3 gm.  to  20.0  cc.)  ;  infu- 
sion of  i|)ecac,  0.3  gm.  to  100.0  cc. ;  together  with  liquor 
ammonii  anisatus,  1  to  1.5  gm.,  or,  as  stimulants,  tritu- 
rates of  camphor  and    benzoic  acid^  of  each  0.015  gm., 


CROUPOUS  PNEUMOMA  333 

every  one  or  two  hours.  For  (lelaye<l  resolution  admin- 
ister Ji  cliikl's  spoonful  of  potassium  iodid  (2  to  3  ^tn.  to 
100  ce.)  every  two  hours;  oxygen  for  dyspnea.  Cham- 
pagne, eamphor,  or  injeetion  of  ether  for  threatening 
heart  failure.     Venesection  for  threatening  asphyxiation. 

CROUPOUS  PNEUMONIA 

{Fibrinous  Pneumonia;  Lobar  Pneumonia) 

Aside  from  bronchopneumonia  with  its  atypic  exu- 
date we  also  find  fairly  frequent  in  children,  especially 
during  the  first  five  years,  croupous  j)neumonia,  which 
begins  with  a  high  fever,  runs  an  acute  course,  and  is  ac- 
com})anied  by  a  ])urely  fibrinous  and  slightly  cellular 
exudate.  The  micro-organisms  mentioned  in  the  last 
disease  arc  the  etiologic  factors.  The  irritation  cjuised 
by  these  bacteria  involves  directly  and  at  one  time  a  large 
surface  of  the  alveolar  epithelimn,  so  that,  unlike  bron- 
chopneumonia, instead  of  the  small  inflammatory  foci 
which  gradually  spread,  a  large  area,  usually  a  whole 
lobe,  is  involved  at  once.  The  disease  is  more  prevalent 
in  cold  and  wet  weather,  and  is  l)rought  on  by  those  fac- 
tors which  lessen  the  resisting  forces  of  the  organism,  as 
circulatory  disturbances.  Croupous  ])neumonia  of  chil- 
dren presents  no  special  etiologic,  anatomic,  or  clinical 
diiferences  from  the  same  disease  in  adults.  The  pre- 
viously described  micVo-organisms  are  present ;  anatom- 
ically the  stages  of  inflammatory  engorgement  exist,  that 
is,  hepatization  and  purulent  infiltration,  also  a  localized 
fibrinous  pleurisy.  The  clinical  sym])toms  consist  of  u 
sudden  onset,  with  vomiting,  chilly  sensations,  rarely 
convulsions  ;  a  high,  continuous  fever,  dyspnea  with  |>ain 
in  the  side,  cough,  and  a  rust-colored  sputum.  Percus- 
sion reveals  slight  dulness.  A  tympanitic  sound  is  elic- 
ited on  deeper  percussion  over  a  whole  lobe  or  a  large 
portion  of  it.  On  auscultation  crej)itant  rales,  exagger- 
ated or  weakened,  and  indefinite  l)reathing  are  heard. 
Later  there  is  pronounced  dulness,  bronchial  breathing, 
bronchophony,  and  increased  vocal  fremitus.     In  favor- 


334  RESPIRATORY  DISEASES 

able  cases  resolution  is  accompanied  by  disappearance  of 
the  symptoms  in  the  same  order  as  in  their  development. 
The  fever  disappears  by  crisis — rarely  by  lysis — on  the 
fifth  to  the  ninth  day  (exceptionally  earlier  or  later), 
usually  with  continued  severe  perspiration.  Character- 
istic of  croupous  pneumonia  in  childhood  is  the  beginning 
in  young  children  with  vomiting,  convulsions,  and  a 
slight  chilliness,  instead  of  the  marked  chills  of  adults ; 
also  a  pulse  and  resi)iration  rate  corresponding  to  the 
height  of  the  fever,  the  development  of  symptoms  of 
cerebral  irritation,  and  a  more  rapid  convalescence  than 
in  adults.  When  lobar  pneumonia  occurs  at  the  close  of 
an  acute  infection,  absence  of  reaction  on  the  part  of  the 
organism  interferes  with  the  typic  course,  and  the  exu- 
date fails  to  undergo  the  usual  resolution.  This  type  is 
more  likely  to  be  protracted  and  terminates  frequently  in 
death  or  in  caseation  or  connective-tissue  new  growth 
(Ziemssen).  The  primary  form  of  pneumonia  in  young 
children  may  also  offer  diagnostic  difficulties.  The  sub- 
jective symptoms  are  absent,  usually  the  characteristic 
sputum  also,  and,  as  mentioned  above,  the  initial  chill. 
Cough,  shortness  of  breath,  and  pain  in  the  side  are  fre- 
quently pronounced.  The  diagnosis  is  especially  difficult 
when  the  pneumonia  is  of  central  origin.  For  example, 
in  pneumonia  of  the  upper  lobes,  in  which  case  the  phys- 
ical signs  usually  do  not  develop  until  the  fourth  or  fifth 
day,  and  the  presence  of  cerebral  manifestations  may  lead 
to  suspicion  of  a  cerebral  or  meningeal  affection.  The 
following  facts  are  of  assistance  in  making  the  diagnosis 
of  croupous  pneumonia  :  Leukocytosis,  acetonuria,  diace- 
turia,  herpes  labialis  (less  common  in  children  than  in 
adults),  and  disajipearance  of  the  patellar  tendon  reflex 
(not  until  after  the  third  year  of  life — Pfaundler). 

Differential  Diagnosis. — In  capillary  bronchitis,  atelec- 
tasis, and  bronchopneumonia  the  child  is  pale  and  cyanotic, 
whereas  in  croupous  pneumonia  the  initial  stage  is  accom- 
panied by  marked  redness  of  the  cheeks.  In  the  first 
disease  the  pulse  is  small  and  soft,  but  in  croupous  pneu- 
monia, full   and   hard.      Bronchopneumonia    progresses 


CHRONIC  PNEUMONIA  335 

with  the  gradual  development  of  catarrhal  symptoms,  the 
areas  of  diilness  are  smaller,  and  the  temjwratiire  is  nor- 
mal or  of  a  mcxlerate  height.  (For  the  characteristics  of 
Caseous  Pneumonia,  see  that  disease.)  The  dyspnea 
is  less,  the  temperature  rarely  rises  as  high  as  in  croupous 
pneumonia,  and  shows  an  irregular  morning  rise,  or  the 
typhus  inversus.  Croupous  pneumonia  accompanied  by 
cerebral  symptoms  is  distinguished  from  meningitis  by 
the  mildness  and  lack  of  constancy  of  the  nervous 
manifestations,  the  regular  and  rapid  pulse,  the  simulta- 
neous development  of  symptoms  of  a  pulmonary  disease, 
and,  finally,  the  loss  of  patellar  reflex  (which  is  increased 
in  meningitis).  The  temperature  of  meningitis  does  not 
show  the  influence  of  critical  days. 

Prognosis. — Croupous  pneumonia,  as  a  rule,  runs  a  favor- 
able course  in  children  previously  healthy  and  strong  and 
who  have  been  brought  up  under  favorable  conditions  of 
life.  Death  may  follow  ])ulmonary  edema  when  the  in- 
flammation is  very  extensive,  or  a  complicating  pleurisy, 
pericarditis,  or  meningitis  (otitis,  nephritis).  Tubercu- 
lous infection  of  the  exudate  in  weak  scrofulous  individ- 
uals may  also  cause  death. 

Treatment. — General  hygienic  and  dietetic  measures  as 
•in  bronchitis  and  bronchopneumonia.  Of  especial  im- 
portance is  a  strengthening  liquid  diet.  Cleanliness  of 
the  mouth.  Regular  bowel  movements.  Cold  pack; 
batiis,  with  cool  douches  and  subsequent  vigorous  rubbing 
(omit  all  hydrotherapeutic  procedures  at  the  time  of 
crisis).  In  case  of  heart  failure  and  somnolence  give 
camphor,  ether,  or  champagne.  For  extreme  dyspnea,  in- 
halations of  oxygen.  Employ  the  ice-bag  for  severe 
nervous  phenomena.  In  case  of  delayed  resolution,  moist 
warm  pack  and  iodin  preparations, 

CHRONIC  PNEUMONIA 

(Bronchierlitsis) 

The  passing  of  a  pneumonia  into  the  chronic  stage 
(bronchiectasis)  occurs  more  frequently  in  catarrhal  than 
in  croupous  pneumonia.     It  is  marked  by  inspissation  of 


336  RESPIRATORY  DISEASES 

the  alveolar  contents  and  proliferation  of  the  interstitial 
connective  tissne  with  consecutive  contraction  of  the 
parenchyma.  The  child  is  anemic,  emaciated,  and  sal- 
low; every  exertion  is  accompanied  by  shortness  of  breath 
and  cough  is  constant.  A  remittent  or  intermittent  fever 
with  afebrile  intervals  exists  ;  also  dyspepsia  and  profuse 
sweats.  Ijocally :  Dulness,  indefinite  or  bronchial  breath- 
ing, and  rales  ;  mucopurulent  expectoration.  The  affected 
side  of  the  thorax  is  contracted  when  the  lung  shrinks. 

Bronchiectasis  may  not  only  follow  pulmonary  contrac- 
tion, but  may  also  be  due  to  continued  increased  inspira- 
tory or  expiratory  pressure.  The  latter  occurs  when  the 
inflammatory  process  in  chronic  purulent  bronchitis  j)onc- 
trates  the  bronchial. wall  and,  involving  the  surrounding 
tissue,  causes  the  bronchial  wall  to  become  gradually 
thin,  soft,  yielding,  and  its  elasticity  damaged.  This  is 
especially  likely  to  develop  in  the  course  of  the  pneu- 
monia developing  in  diphtheria,  whooping-congh,  and 
measles.  A  severe,  troublesome,  and  spasmodic  cough, 
which  arises  chiefly  in  the  morning  and  evening,  brings 
up  a  thin,  purulent,  greenish  expectoration  which  has  a 
foul  odor ;  this  discharge  not  rarely  gushes  forth  from 
the  nose  and  mouth  and  forms  layers  in  the  vessel  in 
which  it  is  collected.  Characteristic  of  this  condition 
are  the  changes  in  percussion  and  auscultation  as  the 
cavity-like  dilated  bronchus  becomes  filled.  The  symp- 
toms of  a  cavity  are  presented  when  a  large  expansion 
of  the  bronchus  occurs  superficially.  A  cure  is  impos- 
sible in  indurated  interstitial  pneumonia  and  bronchiec- 
tasis. The  resorption  of  an  inspissated  exudate  may, 
however,  occur  after  a  period  of  weeks,  provided  case- 
ation or  tuberculosis  do  not  develop. 

The  treatment  of  this  chronic  disease  of  the  lungs 
must  preferably  be  hygienic  and  dietetic.  Breathe  air 
which  is  free  from  dust ;  sojourn  at  the  sea,  mountains, 
or  winter  resorts.  Woolen  underclothing.  A  strengthen- 
ing diet  which  is  rich  in  fats.  Cod-liver  oil.  Tepid 
baths.  Priessnitz's  compresses.  Turpentine  inhalations 
for  bronchiectasis. 


PLEURISY  337 

PLEURISY 

Pleurisy  occurs  quite  frequently  in  children,  especially 
at  the  middle  period  of  childhood,  and,  as  a  rule,  second- 
ary to  or  as  an  associated  manifestation  of  disease  else- 
where in  the  lungs  or  to  a  constitutional  condition.  In 
exceptional  cases  pleurisy  is  primary  in  origin,  due  to 
cold  or  trauma.  Pleurisy  develops  as  in  adults  in  the 
dry,  fibrinous,  or  exudative  form  ;  the  latter  tyix?  is  des- 
ignated according  to  the  character  of  the  exudate. 

Serous  or  serofibrinous  pleurisy  is  accompanied  by  the 
excretion  of  a  clear,  yellowish  fluid,  whicii  is  poor  in 
cellular  elements  and  chiefly  composed  of  serum  contain- 
ing more  or  less  fibrin. 

Purulent  pleurisy,  or  empyema,  is  associated  with  an 
abundant  cellular  purulent  exudate,  which  may  become 
decomposed  by  the  entrance  of  putrefactive  bacteria  and 
give  forth  a  fetid  odor  (ichorous  empyema). 

Hemorrhagic  pleurisy  is  characterized  by  a  serous  fluid 
whicli  is  colored  reddish  or  brownish  red  by  the  admix- 
ture of  red  blood-cells.  The  development  of  a  pleurisy 
is  due,  on  the  one  hand,  to  the  entrance  of  large  masses 
of  pathogenic  bacteria  or  their  virus,  and  on  the  other,  to 
alterations  in  the  pleura  through  disease  processes  of 
neighboring  organs,  trauma,  exposure  to  cold,  diseases  of 
the  blood,  and  disturbances  of  circulation.  The  entrance 
of  bacteria  or  their  toxins  follows  either  from  the  blood 
or  lymph-vessels  or  directly  from  the  diseased  neighbor- 
ing organs.  In  the  first  case  the  pleurisy  is  an  expression 
of  a  constitutional  infection  ;  in  the  second,  it  is  usually 
the  result  of  pulmonary  diseases.  Pleurisy  is  also  fre- 
quently associated  with  an  acute  infectious  disease,  in 
which  case  a  specific  infection  is  not  always  at  fault,  for 
it  is  more  likely  that  the  disease  produces  only  a  predis- 
position of  the  pleura  to  secondary  involvement.  A  by 
no  means  small  percentage  of  pleurisies  are  of  a  tuber- 
culous nature.  In  pneumococcus  pleurisy  we  find  this 
organism  most  frequently,  whereas  in  pleurisy  following 
an  acute  infectious  disease,  streptococci  and  stiiphyloc<x.*ci 
are  most  likely  to  be  found. 
22 


338  RESPIRATORY  DISEASES 

Symptoms. — The  disease  often  begins  very  gradually, 
with  insignificant  symptoms  which  are  barely  noticeable 
and  consist  of  a  slight  cough,  mild  dyspnea,  and  a  mod- 
erate increase  of  fever  toward  evening.  In  other  cases 
it  has  a  sudden  onset,  with  headache,  vomiting,  chills,  high 
fever,  short,  suppressed,  very  rapid  breathing,  and  pain 
in  the  side,  which  is  made  worse  by  respiration  and  mo- 
tion. The  aifected  half  of  the  chest  is  usually  contracted 
in  children  and  shows  diminished  respiratory  excursion. 
Percussion  is  negative ;  auscultation  reveals  weakened 
breath  sounds  and  sometimes  circumscribed  friction-rub 
at  the  height  of  inspiration — dry  plearisi/. 

If  an  exudate  develops  in  a  few  days  the  findings 
change  considerably.  The  friction-rub  gradually  disap- 
pears (until  the  beginning  of  absorption),  the  whole  dis- 
eased side  bulges,  shows  obliterated  intercostal  spaces,  and 
shares  only  slightly  or  not  at  all  the  movements  of  the 
rest  of  the  chest.  Breathing  is  dyspneic  and  painful. 
To  relieve  the  pain  the  patient  lies  on  the  diseased  side. 
As  soon  as  the  exudate  measures  60  ccm.  or  more  we  ob- 
tain dulness  over  the  affected  area,  yet  the  dulness  is 
rarely  as  absolute  as  in  adults,  for  in  the  infantile  thorax 
percussion  also  elicits  the  tone  of  the  air-containing  por- 
tions. If  the  collection  of  fluid  is  large,  dislocation  of 
the  heart  or  liver  occurs,  and  if  it  is  on  the  left  side,  the 
Traube's  space  is  obliterated.  Palpation  shows  tender- 
ness to  pressure  and  a  sense  of  resistance  in  the  dull 
area ;  vocal  fremitus  is  diminished.  On  auscultation 
diminished  bronchial  breathing  is  heard,  as  well  as  bron- 
chophony, which  is  even  audible  over  the  compressed 
limg,  since  the  dimensions  of  the  infantile  thorax  are  too 
small  to  interfere  with  the  conduction  of  consonant  tones 
(Ziemssen).  When  pleurisy  occurs  during  the  course  of 
a  pneumonia  or  as  a  sequel,  the  high  temperature  of  the 
pneumonia  persists  and  bronchial  breathing  and  broncho- 
phony are  louder,  the  dulness  almost  absolute,  and  the 
pectoral  fremitus  preserved.  In  empyema  we  note  col- 
lateral edema  of  the  soft  tissues  lying  over  the  suppura- 
tive focus,  a  high  septic  fever,  and  decided  disturbance  of 


PLEURISY  339 

the  general  health.  If  the  exudate  exists  in  large  quan- 
tities the  health  is  rapidly  undermined  and  the  symptoms 
of  carbonic-acid-poisoning  develop ;  the  physical  symp- 
toms of  a  serous  exudate  are  present. 

The  course  and  result  of  pleurisy  is  dependent  upon 
the  etiologic  factors,  the  age,  and  the  strength  of  the  pa- 
tient. Dry  pleurisy  and  serofibrinous  pleurisy  with 
slight  exudate  may  heal  in  one  week,  but  if  the  excretion 
is  abundant  the  course  may  be  prolonged  over  weeks  and 
months.  Cases  accompanied  by  the  rapid  development 
of  a  large  amount  of  exudate  are  always  doubtful  as  re- 
gards the  prognosis,  especially  in  young  children.  Em- 
pyema may  rupture  spontaneously — externally  or  into  the 
compressed  lung.  Pleurisy  is  frequently  followed  by  in- 
duration, contraction,  deformity  of  the  thorax,  and  scolio- 
sis. Serious  complications  and  sequelae  include  consecu- 
tive inflammation  of  neighboring  organs,  tuberculosis, 
chronic  bronchial  catarrh,  and  bronchiectasis.  The  con- 
tinuance of  the  fever  after  an  operation  for  empyema 
should  lead  one  to  suspect  other  purulent  foci  (Vierordt). 

The  diagnosis  may  remain  uncertain  for  a  long  time. 
Constant  manifestations  of  an  exudative  pleurisy  are  a 
persistent  tendency  to  lie  on  the  same  side,  cough,  pain  in 
the  side,  dyspneic  breathing  without  accentuation  of  ex- 
piration (pneumonia),  a  resistant  dulness,  and  bronchial 
respiration.  On  the  other  hand,  pectoral  fremitus,  which 
is  so  important  in  reaching  a  decision,  is  under  all  circum- 
stances demonstrable  with  difficulty  in  children  ;  sputum 
is  rarely  ever  procurable  ;  the  percussion-note  is  absolutely 
dull  only  when  a  very  large  exudate  or  a  pneumococcus 
pleurisy  is  present,  and  the  respiratory  murmur  and  the 
voice  do  not  show  the  characteristic  weakness  seen  in 
adults.  Friction-rub  may  be  absent.  Thus,  no  conclu- 
sion may  be  reached  until  later  in  the  course  of  the  dis- 
ease or  by  means  of  an  exploratory  puncture.  (The  fluid 
thus  removed  should  always  be  examined  microscopic- 
ally, and  if  it  is  found  to  contain  only  a  few  bacteria 
and  mononuclear  leukocytes  are  present,  the  exudate  is 
probably  tuberculous,  whereas  the  presence  of  numerous 


Fig.  111. — Drainage  and  dressing 
after  resection  of  a  rib. 


\  340 


PLEURISY  341 

micro-organisms  togetlicr  with  polynuclear  leukocytes, 
speak  against   tuberculosis.) 

Differential  Diagnosis  Between  Pleurisy  and  Pneumonia. 
— The  fever  is  rarely  as  high  in  the  former,  it  is  atypic, 
the  dulness  is  more  resistant,  and  spreads  uniformly  over 
the  posterior  and  anterior  half  of  the  chest,  whereas  in 
pneumonia  the  infiltration  does  not  extend  anteriorly 
until  later.  A  tympanitic  note  is  obtained  above  the 
dulness.  Weak  breath  sounds  and  vocal  fremitus  absent. 
Traube's  space  is  preserved  in  pneumonia. 

Treatment. — If  fever  be  present,  rest  in  bed.  A  non- 
irritating  diet  with  limitation  of  liquids.  In  recent  cases 
apply  ice-bags ;  for  troublesome  cough  give  narcotics. 
To  excite  resorption  apply  wet  pack,  also  resort  to  rub- 
bing in  locally  iodovasogen  or  ichthyol  vasogeu.  If  the 
exudate  is  excessive  and  the  dyspnea  is  pronounced,  punc- 
ture with  a  trocar  and  remove  a  portion  of  the  exudate 
by  means  of  an  aspiration  apparatus  (simple  piston- 
syringe  with  a  double  stopcock  or  the  aspirator  of 
Dieulafoy-Potain).  Puncture  the  fifth  or  sixth  inter- 
space at  the  anterior  axillary  line.  In  case  of  empyema 
a  rib  should  be  resected  (seventh  rib  at  posterior  axillary 
line)  and  followed  by  drainage ;  this  is  best  performed  by 
introducing  a  glass  tube  joined  to  a  rubber  one,  which 
empties  into  a  receiving  vessel  containing  a  solution  of 
carbolic  acid  ;  the  wound  is  dressed  with  a  thick  layer  of 
cotton.  Better  drainage  is  obtained  in  children  on  ac- 
count of  the  narrowness  of  the  intercostal  space  by  resec- 
tion of  a  rib  than  by  means  of  the  Biilau  method  of 
drainage,  which  is  so  extensively  practised  in  the  case  of 
adults.  In  place  of  the  latter  an  attempt  may  be  made 
in  very  young  children,  or  in  patients  already  debilitated, 
by  means  of  the  E.  Midler  permanent  cannula,  which 
consists  in  introducing  by  means  of  a  trocar  a  curved 
metallic  cannula  furnished  with  a  shield.  After  the  ])us 
has  been  removed  ap])ly  a  tight  cotton  and  gauze  dress- 
ing. During  convalescence  give  a  strengthening  diet, 
cod-liver  oil,  extract  of  malt,  the  iodid  of  iron,  respira- 
tory exercises,  and  sojourn  in  the  country. 


DISEASES  OF  THE  DIGESTIVE  ORGANS 

DISEASES  OF  THE  MOUTH  AND  PHARYNX 

GENERAL  DISCUSSION 

Diseases  of  the  mouth  and  pharynx  represent,  next 
to  gastro-intestinal  diseases,  the  commonest  affections 
of  the  early  years  of  childhoml.  Certain  physioloffic 
peculiarities  of  the  infantile  oral  cavity,  and  especially 
the  sensitiveness  of  the  mucous  membrane  to  injurious 
external  influences  of  all  varieties,  favor  a  predisposition 
to  various  diseases.  The  true  etiologic  factors  of  this 
disease  include  mechanical,  thermic,  and,  above  all, 
bacterial  irritants.  The  disease  process  may,  however, 
develop  to  a  certain  extent  as  a  sequal  to  diseases  of  the 
gastro-intestinal  tract  or  constitutional  anomalies. 

BEDNAR'S  APHTH/E 

Bednar's  aphthae  are  small  superficial  ulcers  at  both 
sides  of  the  palatine  raph6,  where  the  palatine  mucous 
membrane  is  tightly  drawn  over  the  hamulus  of  the 
pterygoid  bone.  The  entrance  of  bacteria  through  suck- 
ing or  swabbing  out  of  the  mouth  converts  ci)itholial 
defects  which  have  followed  pressure  or  rubbing  into 
grayish-white,  round,  or  oval  ulcers  surrounded  by  a  red 
areola ;  these  ulcers  heal  in  a  short  time  by  the  formation 
of  new  epithelium.  Treatment  is  unnecessary.  (A 
miliary  collection  of  epithelial  cells  in  the  raphe  of  the 
palate  is  a  frequent  physiologic  condition  of  nursing  in- 
fants.) 

STOMATITIS 

Catarrhal  stomatitis  is  an  inflammation  of  tlie  oral 
mucous  membrane  which  manifests  itself  only  by  redness, 
swelling,  and  tenderness  of  the  mucous  membrane,  which 
tends  to  bleed  easily,  as  well  as  increased  salivation.    The 

342 


STOMATITIS  343 

condition  heals  in  a  few  clays,  provided  the  mouth  is  kept 
thoroughly  cleansed  and  a  non-irritating  diet  administered. 
The  abundant  secretion  of  the  oral  mucous  membrane 
does  not  possess  a  foul  odor  as  in  aphthous  and  ulcerative 
stomatitis.  Etiologic  factors  are  the  irritation  incident  to 
eruption  of  the  teeth  and,  far  more  frequently,  ectogenic 
and  endogenic  infection  of  the  oral  cavity  by  various  bac- 
teria due  to  neglect  of  the  mouth  and  teeth ;  in  infants 
infection  occurs  not  rarely  due  to  careless  swabbing  out 
of  the  mouth  (Stooss,  Epstein). 

Aphthous  stomatitis  is  an  inflammatory  and  at  times 
epidemic  condition  of  the  mouth  due  to  distinct  forms  of 
bacteria  (also  the  etiologic  factor  of  foot-and-mouth  dis- 
ease). The  symptoms  of  catarrhal  stomatitis  are  accom- 
panied by  the  ])resence  on  the  oral  mucous  membrane  of 
small,  round,  grayish-yellow  exudations  surrounded  by  a 
red  areola,  or  in  place  of  them,  after  the  epithelium  has 
been  removed,  are  seen,  corresponding  in  size,  ulcerated 
areas  covered  by  a  lardaceous  material.  The  oral  secre- 
tion has  a  somewhat  foul  odor.  The  general  health  is 
considerably  disturbed  and  at  times  a  fever  of  39°  to 
40°  C.  [102.2°-104°  F.]  sets  in.  The  painfulness  of  the 
inflamed  mucous  membrane  interferes  with  the  ingestion 
of  food.  Ne})hritis  is  an  occasional  complication  (Seitz, 
Hagenbach).  Recovery  occurs  in  from  eight  to  ten 
days. 

Diagnods. — When  the  aphthae  develop  primarily  upon 
the  isthmus  of  the  fauces  it  is  possible  to  make  an  error 
in  diagnosis  and  call  the  condition  lacunar  angina,  at 
least  until  the  affection  has  spread  throughout  the  oral 
cavity. 

T^'eatment—^wnh  the  aphthaj  with  1  to  2  i)er  cent, 
solution  of  silver  nitrate,  or  the  silver  stick,  or  the  tinc- 
ture of  rhatany  may  be  applied.  Wash  the  mouth  with 
a  disinfectant  solution,  [such  as  Dobell's  solution,  or  a 
solution  of  chlorate  of  potash  (3  per  cent.),  or  hydrogen 
peroxid  (1  teaspoonful  to  1  ounce)].  When  the  ingestion 
of  food  is  interfered  with,  anesthetize  the  mucous  mem- 
brane with  aneson. 


344     DISEASES  OF  THE  MOUTH  AND  PHARYNX 

PLATE  35 

Fia.  1.  Aphthous  Stomatitis  and  Begrlnning  Ulcerative  Stomatitis. 
— The  oral  mucous  uiembrauc  is  diU'usely  redileiiod  aud  swollen  and  has 
a  moist,  glossy  appearance.  Deposited  ou  the  mucous  membnine  is  au 
exudate  which  is  either  rounded  or  irregularly  formed ;  the  dopositjj 
vary  in  size  from  a  piu  head  to  a  lentil  aud  are  of  a  grayish-yellow  color 
surrounded  by  a  dark  red  zoue  (aphthae).  The  gums  show  a  livid  dis- 
coloration ;  tliey  are  relaxed,  tend  to  bleed  readily,  aud  ])roject  from  the 
teethlike  growths.  In  some  areas  the  edges  have  a  yellow,  pulpy  ap 
pearance,  where  beginning  ulceration  is  also  noted.  Increased  saliva- 
tion ;  fetor  of  the  breatii. 

Fu;.  2.  Thrush  of  the  Oral  Cavity.— The  oral  mucous  membrane  is 
dry  and  brick-red  in  color.  Colonies  of  thrush  are  seen  on  the  lips,  the 
buccal  mucosa,  on  the  hard  and  soft  palate,  and  especially  numerous  u\wu 
the  tongue;  these  foci  are  either  puncti form  or  spread  out  over  a  large 
surface.  The  larger  deposits,  which  are  less  tightly  adherent,  have  been 
partially  loosened  by  the  movements  of  mastication  and,  becoming  dry, 
show  a  dirty  yellow  discoloration. 

XHcerative  Stomatitis  (see  Noma). — Ulcerative  stoma- 
titis is  a  peculiar  form  of  stomatitis,  exteiuling  always 
from  the  neighborhood  of  the  teeth,  which  is  generally 
confined  to  the  gums,  and  is  characterized  hy  a  tendency 
of  the  gums  to  undergo  ulceration  and  by  a  jX-Mietniting 
putrefactive  odor  of  the  oral  secretions.  It  is  caused  by 
intoxication  with  mercurial  preparations,  constitutional 
anomalies  (scorbutus,  diabetes),  or  by  various  bacteria 
(specific  micro  organisms  found  are  spirochetae,  Bticillus 
fusiformis — Bcruheim). 

Si/mptoms. — The  outer  border  of  the  gums  is  reddened 
and,  later,  discolored  livid  ;  it  is  covered  by  a  yellowish 
pulp  and  tends  to  bleed  easily.  An  inflammatory  exudate 
swells  and  relaxes  the  gums  to  such  an  extent  that  they 
are  elevated  from  the  teeth  like  new  growths.  Through 
epithelial  necrosis  it  is  converted  into  a  smeary  and  dis- 
colored ulcer,  which  po.ssesses  an  extremely  Un\\  odor. 
The  affection  may  spread  by  contact  to  neighboring  soft 
parts.  The  tonsils  may  even  be  involved,  on  account  of 
which,  under  certain  circumstances,  the  disease  may  be 
mistaken  for  lacunar  angina  ;  when  the  disease  process  is 
confined  to  the  tonsils  and  near-l)y  structures  we  speak  of 
ulcerative  angina  (aiif/ina  ulcerosa).  The  general  health 
suffers  markedly  from  interference  with  nutrition  and  the 
absorption  of  putrefactive  products.     Healing  occurs  in 


I 


V''*"^^ 


THRUSH  345 

from  ten  to  fourteen  days ;  in  cachectic  cliildren,  however, 
tlie  necrotic  area  may  spread  and  death  occurs,  due  to  gen- 
eral sepsis. 

Bkujuonis. — In  the  diflPerential  diagnosis  lacunar  angina 
and  herpetic  angina  must  be  considered.  In  the  latter  an 
acute  rise  in  temperature  occurs,  together  with  the  appear- 
ance of  herpetic  vesicles  upon  the  mucous  membrane, 
which  undergo  rapid  destruction. 

Treatment. — Potassium  chlorate  acts  as  a  specific  in  this 
condition  (3  per  cent,  solution  for  gargling  and  1  percent, 
solution  internally). 

THRUSH 

Thrush  is  a  jjeculiar  type  of  stomatitis  which  is  due  to 
the  deposition  of  the  fungus  Saccharomyces  albicans  upon 
the  oral  mucous  membrane. 

Symptoms  and  Course. — The  irritation  caused  by  the 
presence  of  the  fungus  in  the  epithelium  produces  inflam- 
mation of  the  mucous  membrane  with  redness,  swelling, 
and  pain.  Small  milk-white  thrush  colonies  soon  show 
themselves  upon  the  mucosa,  and  if  their  growth  is  undis- 
turbed they  rapidly  enlarge,  and,  coalescing,  cover  large 
areas  of  the  mucous  membrane  with  a  thick,  dirty  white 
coat.  Primarily  only  the  tongue  and  inner  surface  of 
the  cheeks  are  involved,  but  later  the  lips  and  palate  are 
included.  The  process  may  occasionally  descend  to  the 
stomach,  rarely  further.  The  entrance  of  the  fungus  into 
the  blood  current  may  lead  to  metastasis  to  the  internal 
organs. 

Thrush  is  not  altogether  a  harmless  disease.  Aside 
from  the  local  disturbances  due  to  the  presence  of  the  fun- 
gus upon  the  mucous  membrane,  which  interferes  with  the 
ingestion  of  food  and  makes  that  procedure  painful, 
another  ])roperty  is  to  be  considered — the  tendency  to 
cause  fermentation.  As  a  result,  the  swallowing  of  the 
thrush  fragments,  together  with  the  products  of  fermenta- 
tion, is  not  infrequently  the  cause  of  dyspepsia  and  even 
inflammation  of  tlie  intestines  (thrush  enteritis). 

Diagnosis. — When  the  diagnosis  is  in  doubt  (diphther- 


346     DISEASES  OF  THE  MOUTH  AND  PHARYNX 


itic  deposit  ?),  a  microscopic  examination  should  be  made 
for  the  presence  of  the  network  of  the  mycelium,  the 
egg-shaped  cells,  together  with  the  small  shiny  spores. 

Treatment. — The  fungoid  coat  must  be  removed  as  soon 
as  possible  by  swabbing  with  borax,  boric  acid,  hydrogen 
peroxid  (1  teaspoonful  to  1  ounce),  or  normal  salt  solution. 
This  is  performed  with  difficulty  if  the  condition  is  of 
long  standing,  and  can  only  be  accomplished  at  the  ex- 
j)ense  of  hemorrhage  from  the  mucous  membrane,  since 
the  mycelium  ha>  pcnotratcd  into  tlie  deeper  layers  of  the 


Fig. 


112. — Microscopic  picture  of  a  thrush  deposit  removed  from  the 
mouth.     Enlarged  350  times. 


mucosa.  After  swabbing,  paint  with  1  to  2  per  cent,  silver 
solution  (Henoch).  This  must  be  frequently  repeated  be- 
cause of  the  tendency  to  relapse.  As  a  preventive  meas- 
ure, the  sucking  bag  of  Escherich  [containing  borax]  is 
recommended. 

NOMA 

Noma  is  a  very  rare  gangrene  of  the  cheek  of  bacterio- 
logic  origin.  It  begins  with  the  development  of  a  nodule 
on  the  inner  surface  of  the  cheek,  which  is  converted  into 


ANOTNA  347 

a  vesicle.  The  latter  ruptures  and  leaves  a  grayish-brown 
scab  behind.  As  the  process  progresses  toward  the  skin 
a  rose-colored  and,  later,  brownish-blue  spot  appears  on 
the  latter,  and  finally  an  extensive  black  eschar  forms. 
The  inner  surface  of  the  cheek  is  converted  into  a  foul- 
smelling,  smeary,  and  gangrenous  mass.  Death  occurs  in 
from  ten  to  twenty  days.  Spontaneous  cure  is  rare  and 
the  mortality- rate  is  as  high  as  95  per  cent.  An  early 
and  complete  excision  gives  the  best  results  (von  Ilanke). 

ANGINA 

Non-specific  angina  is  a  very  frequent  disease  of  child- 
hood. The  direct  causes  of  this  condition  may  be  strejv 
tococci,  staphylococci,  or  pneumococci,  which,  being  acci- 
dentally deposited  during  an  acute  cold,  dyspepsia,  etc., 
excite  a  catarrh  and  inflammation  of  the  mucous  mem- 
brane of  the  tonsils  and  the  neighboring  structures. 

Symptoms. — The  mild  cases  are  accompanied  only  by 
redness,  swelling,  and  active  secretion  of  the  tonsils — 
catarrhal  angina;  these  manifestations  develop  with  a 
moderate  fever  and  difficulty  in  swallowing,  but  disap- 
pear in  several  days.  In  a  severer  grade  of  inflammatory 
irritation  an  exudate  appears  and  the  local  and  general 
symptoms  are  more  marked.  The  tonsils  are  dark  red, 
covered  with  a  shiny  mucus,  and  show  disseminated  yellow 
specks  (lacunar  exudate  containing  large  numbers  of  bac- 
teria and  cells,  but  little  fibrin) — lacunar  angina  (see 
Plate  25  and  Fig.  96).  The  swelling  and  painfulness  of 
the  inflamed  soft  parts  may  develop  to  such  a  degree  that 
difficulty  in  swallowing  and  even  breathing  results,  and 
the  speech  becomes  nasal.  The  disease  is  always  accom- 
panied by  a  high  fever  and  dysj>eptic  phenomena.  The 
neighboring  lymph-nodes  are  swollen  and  an  initial  vom- 
iting, chill,  and  headache  are  frequently  met  with.  The 
fever  disappears  in  several  days  and  complefe  cure  occurs 
gradually  in  one  and  a  half  weeks.  Recurrences  are  quite 
common  and  occur  sometimes  at  regular  intervals  (Fischl). 
Angina  may  in  some  cases  be  the  point  of  exit  of  a  septic 


348     DISEASES  OF  THE  MOUTH  AND  PHARYNX 

PLATE  36 

Noma  of  the  Cheek. — The  whole  left  half  of  the  face  is  phlegmonous, 
reddened,  and  swollen,  and  the  weeping  eye  is  closed  hy  the  swelling. 
The  lower  portion  of  the  left  cheek  from  the  lower  jaw  as  far  as  the  angle 
of  the  mouth  has  been  converted  into  a  blackish  eschar,  which  is  sur- 
rounded by  an  inflammatory  area  from  which  the  epidermis  has  been 
loosened.  In  the  neighborhood  of  the  ramus  of  the  jaw  perforation  has 
occurred,  from  which,  as  well  as  from  tlie  angle  of  the  mouth,  an  ichor- 
ous exudate  is  seen  to  flow.  Death  imminent.  (Clinic  of  Escherich, 
Vienna.) 


infection,  or  in  other  cases  it  represents  the  primary  focus 
of  a  subsequent  organic  disease,  such  as  endopericarditis, 
appendicitis,  and  polyarthritis.^ 

Less  dangerous,  but  extremely  troublesome  and  painful, 
is  the  development  of  local  suppuration  and  the  formation 
of  a  tonsillar  abscess.  The  latter  may  be  suspected  if 
after  four  or  five  days  the  fever  fails  to  drop  and  the 
local  and  constitutional  symptoms  increase  in  severity. 
The  involved  tonsil  is  phlegmonous,  red,  and  swollen ; 
the  secondary  edema  is  often  so  marked  as  to  threaten 
asphyxiation.     An  incision  offers  immediate  relief. 

Diagnosis. — The  clinical  differentiation  between  diph- 
theritic and  non-diphtheritic  angina  may  sometimes  be  im- 
possible. In  favor  of  the  latter  are  a  high  fever,  marked 
redness,  swelling  and  painfulness  of  the  soft  parts,  bilat- 
eral origin,  slight  extension,  a  rare  tendency  of  the  de- 
posits to  coalesce,  and  their  gruel-like  consistency,  to- 
gether with  the  fact  that  they  adhere  but  slightly  to  the 
lacunar  spaces  ;  also  a  doughy  swelling  of  the  lymph- 
glands  (hardening  in  diphtheria).  However,  all  of  these 
manifestations  may  fail,  in  which  case  a  microscopic  ex- 
amination of  the  discharge  will  decide  the  diagnosis.  In 
the  non-diphtheritic  type  of  angina  this  examination  will 
reveal  little  or  no  fibrin,  a  large  number  of  bacteria  of 
various  forms  ;  whereas  in  diphtheritic  angina  a  large 
amount  of  fibrin  is  present,  few  bacteria,  but  an  over- 

^  In  favor  of  the  etiologic  relationship  between  angina  and  rheu- 
matism is  the  oft-]»roven  fact  that  if  the  tonsils  of  an  individual  in 
whom  frequent  recurrences  of  rheumatism  are  preceded  by  angina  are 
extirpated  the  rheumatism  disappears. 


Tah.36, 


k 


^^ 


'i 


HYPERPLASIA   OF  LYMPH-TISSUE  OF  PHARYNX  349 

whelming  number  of  Loffler  bacilli,  which  are  grouped 
in  nests  (sec  Figs.  93,  94), 

Prophylaxis. — Strict  cleanliness  of  the  mouth  and  teeth. 
Treatment  of  carious  teetli,  the  micro-organisms  of  which 
are  frequently  the  cause  of  chronic  recurring  angina. 

Treatment. — Rest  in  bed,  light  diet,  Priessnitz's  com- 
presses, and  spraying  of  the  pharynx.  Potassium  chlorate 
internally  and  as  a  gargle ;  incision  is  indicated  in  case 
of  abscess  formation.  [Where  rheumatic  infection  is 
suspected,  the  salicylates  are  indicated.— Ed.] 

HYPERPLASIA    OF   THE    LYMPH=TISSUE    OF 
THE    PHARYNX 

At  the  entrance  of  the  nasal  and  oral  cavities  into  the 
pharynx  are  a  number  of  lymphoid  organs,  which  are 
spoken  of  collectively  as  the  pharyngeal  lymph  ring. 
Tills  tissue  in  children  is  frequently  subject  to  chronic 
hyperplasia.  Hyperplasia  of  the  palatine  tonsil — which 
may  be  congenital  or  acquired  by  mechanical  irritation — 
causes  but  slight  disturbance,  but  when  of  a  higher  grade 
it  may  cause  difficulty  in  swallowing  and  breathing.  A 
portion  of  the  tonsil  is  removed  by  tonsillotomy. 

Of  far  greater  clinical  importance  is  hyperplasia  of  the 
pharyngeal  tonsil  (adenoid  vegetations).  The  pharyngeal 
tonsil,  a  furrowed,  S])onge-like  glandular  structure  at  the 
roof  of  the  pharynx,  normally  undergoes  gradual  com- 
plete involution  until  the  age  of  puberty  is  reached.  It 
is,  however,  frequently,  on  account  of  mechanical  and 
thermic  irritation,  the  seat  of  acute  inflammation.  Fever, 
dyspnea,  and  dysphagia  arise.  Sleep  is  frequently  inter- 
rupted for  want  of  air  (falling  back  of  the  tongue,  collec- 
tion of  tenacious  nasal  secretion)  and  nurslings  even  are 
not  rarely  subject  to  eclamptic  attacks  ;  at  other  times 
the  sleep  is  extraordinarily  deep — accompanied  by  enu- 
resis (?).  Should  the  affection  remain  strictly  localized 
(angina  pharyngea)  it  becomes  the  source  of  frequent 
error. 

If  such  inflammations   develop   repeatedly   or   if  the 


350    DISEASES  OF  THE  MOUTH  AND  PHARYNX 


HYPERPLASIA   OF  LYMPH-TISSUE  OF  PHABYNX  351 


Fig.  114.— DiN'ital  exainination  of  the  adenoid  growths.  By  preaa- 
ing  the  check  between  the  teeth  it  becomes  impossible  for  the  paUent  to 
bite  the  examining  finger. 


352     DISEASES  OF  THE  MOUTH  AND  PHARYNX 

pharyngeal  tonsil  becomes  hypertrophic  for  other  reasons 
(scrofula,  hereditary  predisposition),  marked  disturbances 
of  the  general  health  will  arise.  The  growths  filling  the 
nasopharynx,  by  displacement  of  the  posterior  nares, 
interfere  with  the  functions  of  the  nose  as  a  respiratory 
and  olfactory  organ  ;  by  obstructing  the  j)haryngeal  open- 
ing of  the  Eustachian  tube  the  sense  of  hearing  is  im- 
paired,, and  by  exerting  pressure  upon  the  })haryngeal 
vessels  stasis  of  blood  and  lymph  occurs  at  the  base  of 
the  skull.     The  most  significant  of  these  disturbances  is 


Fio.  115. — Adenotomy  by  means  of  Schech's  spoon-forceps. 

the  interference  with  nasal  respiration.  The  air  enters 
only  through  the  mouth,  which  is  kept  open,  with  result- 
ant catarrh  of  the  pharynx  and  air-pas.sages ;  the  breath- 
ing is  noisy  and  during  .sleep,  which  is  frequently  inter- 
rupted and  abnormally  sound,  it  is  snorting.  The 
ingestion  of  liquids  is  (especially  for  nursling.s)  also 
interfered  with.  In  the  course  of  time  organic  changes 
follow:  The  nose,  palate,  upper  jaw,  and  thorax  undergo 
disturbances  of  development.  The  patient  frequently 
complains  of  headache  and  loss  of  ])ower  to  fix  the  atten- 
tion u}X)n  any  subject  for  any  length  of  time  (probably  as 


RETROPHARYNGEAL  ABSCESS  353 

a  result  of  the  stasis).  Furthermore,  there  are  disturb- 
ances of  speech. 

The  diagnosis  is  determined  by  digital  examination  or 
posterior  rhinoscopy,  although  it  may  usually  be  made  by 
the  facial  expression  and  the  palatine  speech.  The  eyes 
look  sleepy  and  are  half  closed,  the  nose  is  noticeably 
small,  and  the  mouth,  which  is  always  oj)ens,  has  a  some- 
what stupid  appearance  (see  Fig.  77).  Inspection  of  the 
oral  cavity  shows  an  elevated  palate  which  has  the  form 
of  a  pointed  arch,  and  it  will  be  noted  also  that  the  velum 
palati  (which  is  generally  thickened)  does  not  lie  back 
against  the  posterior  wall  of  the  pharynx  in  phonation. 

The  treatment  consists  in  jjerforming  adenotoray  by 
means  of  a  ring-knife  or  spoon-forceps.  The  recovery  is 
usually  wonderfully  rapid  and  permanent  if  radical  opera- 
tion is  performed. 

RETROPHARYNGEAL  ABSCESS 

Retropharyngeal  abscesses  are,  as  a  rule,  nither  rare  in 
childhood  and  are  practically  only  observed  in  nursing 
infants.  They  may  be  due  to  suppuration  of  a  retrophar- 
yngeal lymph-node  or  a  burrowing  abscess  (v.  Bokay). 
The  abscess  is  generally  situated  in  the  neighborhood  of 
the  third  or  fourth  cervical  vertebrae  and  involves  the 
esophagus  and  larynx.  As  soon  as  a  certain  size  has  been 
reached  we  note  the  development  of  dysphagia,  regurgi- 
tation of  liquids,  snorting  breathing,  and,  finally,  dysp- 
nea. Externally,  swelling  is  noted  on  the  affected  side 
of  the  neck.  Spontaneous  rupture  or  artificial  opening  of 
the  abscess  is  immediately  followed  by  a  disappearance 
of  all  tlie  untoward  symptoms. 

Retropiiaryngeal  abscess  is  distinguished  from  croup  by 
the  deep  gurgling  sound  heard  with  the  respiratory  mur- 
mur (v.  Bokay)  and  by  means  of  digital  examination, 
which  in  doubtful  cases  of  laryngeal  stenosis  must  never 
be  neglected.  The  same  s3'mptoms  are  noted  in  the  rare 
retrolaryngeal  abscess  which  may  occur  with  decubital 
ulceration  after  intubation,  and  also  primarily  in  nurslings. 
23 


354  GASTttO-INTESTINAL  DISEASES 

QA5TR0-INTESTINAL  DISEASES 

GENERAL  DISCUSSION 

Although  the  gastro-intestinal  diseases  in  older  chil- 
dren run,  on  the  whole,  the  same  course  as  in  adults,  yet 
in  the  earlier  periods  of  life  they  possess  certain  charac- 
teristics as  regards  development  and  course.  Thus, 
severe  symptoms  are  frequently  called  forth  by  injurious 
conditions  which  in  the  adult  elicit  none  or  barely  any  re- 
sponse ;  the  disease  process  spreads  rapidly  over  large  sec- 
tions or  throughout  the  whole  digestive  tract ;  mild  affec- 
tions are  often  rapidly  converted  into  serious  disease  forms, 
thus,  dyspepsia  may  lead  to  catarrh  and  inflammation. 

Etiology. — The  causes  are  not  to  be  sought  for  so  much 
in  external  influences  as  in  the  especial  predisposition  in 
the  nursing  infant  to  diseases  of  tlie  digestive  tract,  which 
are  attributed  to  delayed  development  and  to  the  peculiar 
anatomic  relationships. 

The  miniature  size  of  the  nursling's  stomach,  the  vor- 
tical position  of  that  organ,  the  absence  of  a  fundus, 
the  weak  closure  of  the  cardia,  and  the  irritability  of  the 
gastric  nerves,  all  tend  to  favor  vomiting,  so  that  many 
children  vomit  after  each  meal  {habitual  vomiting)  during 
the  first  three  months  until  the  fundus  begins  to  form. 
This  form  of  vomiting,  contrary  to  that  accompanying 
fermentation,  is  unassociated  with  nausea,  retching,  and, 
as  a  rule,  without  ill  effects  upon  the  general  health. 

The  imperfect  functional  C4ipacity  of  the  gastric  mus- 
cles for  work  and  the  relative  length  of  the  intestines, 
especially  the  large  intestine,  is  frequently  the  cause  of 
habitual  constipation  (not  the  only  causes,  however,  as  the 
same  result  is  produced  by  improper  feeding,  overeating, 
and  painful  rhagades  of  the  anus).  If  at  the  same  time 
there  exist  congenital  displacement  and  anomalous  elon- 
gation of  the  colon,  as  well  as  a  defect  of  its  musculature, 
a  high-grade  obstruction  and  hypertrophy  of  the  large  in- 
testine develops — Hirschsprm}(fs  disease  (Jacobi,  Hirsch- 
sprung, Concetti,  Johannessen). 

The   weakness  of  the  musculature,  the  tenderness  of 


L 


ETIOLOGY  355 

the  mucosa,  the  size  and  number  in  the  latter  of  blood- 
vessels, the  abundance  of  nerve-elements,  and  the  pecu- 
liar fact  that  the  myelin  sheath  of  the  mesenteric  nerves 
is  still  imperfectly  developed,  account  for  the  rapid  ex- 
haustion of  the  intestines  and  the  sensitiveness  of  the 
mucous  membrane  toward  irritation  ;  the  enteralgias  so 
common  in  infants  may  also  be  explained  in  that  manner. 
The  infantile  digestive  apparatus  is  sufficiently  active  as 
concerns  absorption  and  secretion  (Gundobin,'  Heubner) 
and,  indeed,  absorption  proceeds  more  rapidly  than  in 
adidts  because  of  the  relatively  long  intestines.  On  the 
other  hand,  the  digestive  function  is  so  much  greater  in 
comparison  with  the  body  weight  that  this  duty  can  only 
be  performed  properly  provided  it  is  not  subject  to  the 
strain  of  too  rich  a  diet  or  one  assimilated  with  difficulty. 
We  must  also  consider  the  fact  that  digestive  ferments 
like  rennin,  pepsin,  trypsin,  etc.,  are  not  relatively  de- 
layed in  development  as  regards  their  activity  in  young 
infants,  yet,  on  the  other  hand,  that  function  of  fermenta- 
tive substances,  which  in  intermediary  metabolism  con- 
trols subsequent  stages  of  digestion  and  especially  assim- 
ilation of  the  absorbed  mass,  may  be  delayed  in  develop- 
ment in  the  earlier  years  of  life.  Such  may  be  the  cause 
of  manifold  disturbances  of  metabolism,  which  may  also 
at  times  be  the  fundamental  etiologic  factor  of  diseased 
conditions,  as,  for  ejcample,  the  pedatrophy  of  children 
(Pfaundler). 

Aside  from  the  mentioned  internal  factors  of  disturb- 
ances of  digestion  in  children,  a  whole  series  of  external 
influences  are  to  be  considered,  which  may,  with  few  ex- 
ceptions, be  traced  to  improper  care  or  lack  of  it.  Of 
first  importance  is  unsuitable,  insufficient,  or  overabun- 
dant food  which  may  have  undergone  chemic  or  bacterial 
degeneration  ;  also  infection  from  the  child's  surround- 
ings, as  well  as  thermic,  mechanical,  chemic,  and  also, 
probably,  nervous  irritation. 

The  alimentary  disturbances  play  the  most  important 
role.  Breast-fed  children  may  also  suffer  from  this  con- 
dition   when    they  receive  too  much  food,  or  when  the 


366 


G ASTRO-INTESTINAL  DISEASES 


Fig.  116. — Hirschsprung's  disease  before  treatment.     (Clinic  of 
Escherich.)     For  description,  see  p.  358. 


ETIOLOGY 


357 


Fig.  117. 


-Hirsclis])ruii}r's   disease  six  inontlis  after  treatment, 
of  Escberich.)     For  description,  see  p.  358. 


(Clinic 


358  G ASTRO-INTESTINAL  DISEASES 

Figs.  116,  117. — Hirschsprung's  disease.  Boy  three  years  and  nine 
months  old.  Since  birth  sutt'ered  from  constant  intestinal  catarrh,  obsti- 
nate constipation,  alternating  with  diarrhea  and  increasing  abdominal 
distention.  On  examination  the  abdomen  measured  in  circumference 
77  cm.  [30.8  in.]  and  the  body  length  87  cm.  [34.8  in.].  The  diaphragm 
was  situated  abnormally  high,  the  thorax  short  and  noticeably  enlarged 
at  the  base,  abdominal  walls  abnormally  distended  and  presenting  dilated 
veins.  Active  peristaltic  movements  visible,  extending  toward  the  left 
side.  Deficient  abdominal  pressure.  Percussion  :  Distention  of  the  ab- 
domen by  intestines  filled  with  air.  Auscultation  :  Splashing  and  gurg- 
ling sounds.  Palpation  :  Liver,  spleen,  and  kidneys  plainly  palpable, 
abnormally  movable,  the  spleen  enlarged  and  hard.  Examination  of  the 
rectum:  Abnormal  dilatation  of  the  lower  section  of  the  large  intestine, 
which  has  been  con  verted  into  a  smooth-walled  cavity  measuring  20  cm. 
[8  in.]  in  diameter,  whose  anterior  and  upper  walls  are  not  palpable. 
Irrigation  was  followed  by  the  discharge  of  foul- smelling  flatus  and  par- 
tially liquid,  partially  clay-like,  well-digested  stools.  Appetite  good. 
Treatment:  Regular  irrigation  with  solution  of  thymol  ;  massage;  fara- 
dization; binder  to  the  abdomen.  The  child  died  in  six  months  fol- 
lowing surgical  interven^iion. 

mother's  milk  has  been  injuriously  influenced  by  gross 
errors  of  diet  during  the  nursing  period,  or  by  the  admix- 
ture of  bacteria  (staphylococci)  from  the  ducts  of  the 
mammary  glands  (staphylococcus  enteritis,  Moro).  Arti- 
ficially fed  children  are  more  frequently  threatened  with 
gastro-intestinal  diseases,  especially  when  they  are  given 
a  diet  unsuitable  to  their  age,  as,  for  example,  overabun- 
dance of  starchy  foods  before  the  end  of  the  third  month 
(insufficient  diasta.sic  ferment).  The  infantile  digestive 
functions  may  also  be  disturbed  to  a  certain  extent  when 
fed  with  cows'  milk,  although  the  latter  simulates  in  com- 
position the  nutritive  elements  of  woman's  milk,  yet  it  is 
poorer  in  easily  digestible  constituents;  furthermore  it 
cannot  be  drunk  immediately  at  its  source,  for  it  must 
first  receive  special  preparation,  on  account  of  which  its 
digestibility  is  lessened  and  often  becomes  contaminated 
by  bacteria.  Owing  to  the  ability  of  the  digestive  tract 
of  normally  developed  infants  to  functionally  respond 
even  after  a  short  time  to  these  dietetic  changes,  a  diet 
which  is  digested  with  difficulty  may  be  assimilated  pro- 
vided the  amount  of  food  ingested  is  not  disj^roportionate 
to  the  digestive  strength.  Overfeeding — which  is  unfor- 
tunately so  common — leads  to  exhaustion  of  the  intestinal 
and  glandular  epithelium  with  gradually  increasing  fail- 


ETIOLOGY  359 

lire  of  assimilation  of  the  food,  which,  stagnating  in  the 
stomach  and  intestines,  undergoes  abnormal  putrefactive 
changes  (Biedert's  "injurious  food  remnant").  The 
products  of  this  process  (fermentation  of  sugar-albumin- 
ous putrefaction)  create  local  irritation  and  symptoms  of 
general  intoxication  (Escherich,  Heubner). 

Still  another  cause  of  disturbances  of  digestion  is  the 
ingestion  of  food  which  has  undergone  chemic  or  bacterial 
decay.  The  gross  impurities  of  cows'  milk  or  infection 
with  a  specific  pathogenic  germ  (tubercle  bacilli,  etc.)  are 
less  common,  as  these  dangers  are  nowadays  generally 
avoided,  since  it  has  become  the  custom  to  examine  and 
boil  the  milk.  On  the  other  hand,  the  lapse  of  time  be- 
fore cows'  milk  can  be  administered  tends  to  increase  the 
action  of  lactic  acid  bacteria  and  other  saprophytes.  If 
the  milk  has  been  preserved  in  a  low  temperature  it 
simply  turns  sour  on  account  of  fermentation  and  causes 
only  local  symptoms  of  intestinal  irritation  (Marfan, 
Escherich),  whereas,  if  the  milk  has  been  preserved  for 
a  long  time  in  a  high  temperature,  as  during  the  hot 
months,  multiplication  of  those  bacteria  dependent  upon 
heat  will  be  noted,  and  the  milk  will  receive  certain  toxic 
properties  from  their  metabolic  products  which  when  in- 
gested will  cause  pronounced  manifestations  of  intoxica- 
tion (cholera  infantum). 

A  certain  number  of  gastro-intestinal  diseases  are 
either  directly  or  indirectly  attributable  to  the  influence  of 
improper  nursing.  Indirectly  they  are  due  to  impure  and 
damp  air,  dark  dwellings,  lack  of  cleanliness  and  warmth, 
together  with  improper  feeding,  all  of  which  rapidly  ex- 
haust and  overcome  the  inherited  resisting  forces  and  with 
them  the  ability  of  the  intestines  to  perform  their  func- 
tions. Directly,  inasmuch  as  unhygienic  conditions  of 
life  favor  the  development  of  true  intestinal  disturbances. 
These  infections  are  similar  in  the  beginning  and  course 
to  the  specific  intestinal  infections,  such  as  typhoid,  dys- 
entery, and  Asiatic  cholera.  They  are  caused  by  various 
forms  of  infectious  germs  (streptococci  and  bacilli  similar 
to  the  colon  bacillus),  which  enter  the  intestines  by  way 


360  QASTRO-INTESTINAL  DISEASES 

PLATE  37 

Fig.  1.  Tbe  Stool  of  Helena  Neonatorum.— Blackish-red  coagulated 
mass  of  blood  with  slight  admixture  of  meconium.     Dirty  red  areola. 

Fig.  2.  Dyspeptic  Stool  of  a  Breast-fed  Child.— Remuauts  of  milk, 
whitish-gray  aud  green  colored  fat  and  soap  remnants  enclosed  in  yellow 
liquid  mas.ses  of  mucus.  Dirty  yellow  areola.  Odor  and  reaction 
strongly  acid.     (Drawn  by  Dr.  Moro,  Escherich's  Clinic.) 

of  the  mouth  or  anus,  through  the  air,  by  transmission 
from  drin king-cups,  etc.  Here  inflammatory  changes  are 
affected  under  certain  circumstances,  metastasis  occurs 
tlirough  the  injured  intestinal  walls,  and  general  infection 
results.  Streptococcic  enteritis,  described  by  Escherich, 
may  be  mentioned  as  a  type  of  intestinal  infection  depend- 
ent upon  the  nutrition  ;  a  disease  which  tends  to  spread 
in  hospitals  and  foundling  asylums  (Epstein,  E.ossi,  Fin- 
kelsteiu,  Escherich). 

Ssnnptomatology. — The  manifold  etiologic  factors  by  no 
means  indicate  a  similar  variety  of  clinical  symptoms,  for, 
on  the  contrary,  diseases  of  digestion  in  infants  are  usually 
accompanied  by  a  comparatively  uniform  .symptomatol- 
ogy. The  preventive  measures  of  the  orgjinism,  consist- 
ing in  vomiting,  increase  of  peristalsis,  watery  and  mu- 
cous stools,  by  means  of  whiclrthe  action  of  the  injurious 
intestinal  contents  is  shortened  or  at  least  weakened,  vary 
but  slightly  and  according  to  the  character,  intensity,  and 
duration  of  the  injurious  influences  and  the  resisting 
forces  of  the  individual.  Even  grave  organic  changes 
of  the  intestinal  canal  manifest  themselves  by  only  a  few 
variable  symptoms.  It  mu.st  not  be  forgotten  also  that 
the  local  changes  observed  at  necropsy  are  frequently,  in 
a  certain  sense,  contrary  to  the  severity  of  the  symptoms 
during  life  and  offer  no  .satisfactory  explanation  for  them 
(Heubner).  Sharply  defined  disease  pictures  of  intes- 
tinal conditions  in  childhootl  depend  less  upon  the  i)ecu- 
liarity  of  the  symptoms  than  upon  their  characteristic 

grouping. 

DYSPEPSIA 

Dyspepsia  is  a  result  of  injurious  effects  upon  alimenta- 
tion or  disturbances  of  digestion  and  absorption  due  to 
organic  weakness. 


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INTESTINAL  CATARRH  361 

Dyspepsia  following  disturbances  of  fermentation  (in  bot- 
tle-fed children)  :  Regurgitation  and  vomiting  of  non- 
coagulated  milk,  even  if  the  vomiting  does  not  occur 
until  a  certain  time  after  feeding.  Constipation  follows 
the  collection  of  undigested  masses;  formation  of  gas 
(euteralgia). 

Stools. — Pale  yellow,  shaped  in  small  or  large  firm 
nodules,  which  contain  remnants  of  food  and  have  a  stale 
or  foul  odor. 

Marked  insufficiency  of  fat  digestion ;  fat  diarrhea  (Bie- 
dert) :  Excretion  of  abnormal  amounts  of  fat  in  the  stools. 
A  state  of  chronic  diarrhea  usually  exists.     Emaciation.. 

Stools. — White,  fatty,  mucoid;  containing  abundance 
of  soaps,  fatty  crystals,  fat-drops,  and  fat-plaques. 

Acid-fermentation  dyspepsia  in  breast-  and  bottle-fed 
infants  ;  acid  eructations,  vomiting,  and  a  sour  odor  from 
the  mouth.  The  stools,  which  are  increased  in  number 
and  contain  large  masses  of  undigested  or  decomposed 
remnants  of  footl,  are  passed  with  loud  flatus  and  much 
restlessness  on  the  part  of  the  child.  An  abnormal 
amount  of  gas  and  acid  formation  takes  place  in  the 
stomach  and  intestines  with  resulting  distention  of  the 
abdomen,  enteralgia,  loss  of  appetite,  and  a  standstill  or 
loss  of  body  weight.     The  course  is  afebrile. 

Stools. — At  the  beginning  these  possess  a  strong  acid 
reaction  and  odor  (butyric  acid)  ;  at  first  they  are  yellow 
in  color,  then  vary  between  milk  white  and  green  (or 
brown  when  amylaceous  food  is  eaten).  Yellowish-white 
flakes  and  remnants,  consisting  of  fat,  alkaline  soaps,  and 
epithelium,  imbedded  in  bacterial  masses  are  found  mixed 
with  mucus  in  gruel-like  stools.  Microscopic  examina- 
tion discloses  remnants  of  milk,  fatty  detritus,  and  single 
epithelial  cells. 

INTESTINAL  CATARRH 

Intestinal  catarrh  may  be  a  sequel  to  dyspepsia  or  a 
prelude  to  inflammatory  processes. 

Symptoms. — The  intestinal  mucous  membrane  is  hyper- 
emic,  swollen  and  relaxed,  and  a  portion  of  the  opithe- 


362  GASTRO-JNTESTINAL  DISEASES 

PLATE  38 

Fig.  1.  The  Stool  of  Intestinal  Cataxrh. — Aside  from  the  lumpy, 
thrcsid-like,  yellowish-brown  masses  of  mueus,  we  also  see  isolated  gray- 
ish-greeu  dysi)eptic  flakes  and  shreds.  The  whole  is  surrounded  by  an 
extensive  pale,  dirty  green,  sharply  outlined  zone.     Acid  reaction. 

Fig.  2.  The  Stool  of  Infectious  Colitis.— In  the  partly  dark  green, 
partly  ochre  colored,  ;uid  i>artly  colorless  lumps  of  mucus  are  seen  scat- 
tered hemorrhagic  points  and  several  large  drops  of  blood  as  well  as 
whitish  flakes  of  pus.  Narrow,  greenish  areola.  Foul  odor.  Alkaline 
reaction. 

Hum  is  destroyed ;  it  may  excrete  a  watery  fluid  and 
mucus.  The  follicles  are  swollen  and  the  mesenteric 
nodes  are  injected.  Severe  local  symptoms  are  accom- 
panied by  general  toxic  manifestations.  These  include 
vomiting,  frequent  and  copious  watery  and  mucous  stools, 
decrease  of  urinary  secretion,  increased  thirst,  and  active 
peristaltic  movements  in  the  abdomen,  which  is  sensitive 
to  pressure.  The  urine  frequently  contains  albumin.  A 
rapid  decline,  and  at  times  clonic-tonic  twitchings  and 
toxic  dyspnea  are  noted.  Fever  develops,  especially 
when  the  stomach  is  markedly  involved. 

Stools. — These  are  passed  in  spurts,  with  much  noise, 
and  are  at  first  similar  to  those  of  acid  dyspep.sia,  yet 
contain  a  marked  increase  in  water  and  mucus.  Later 
they  become  less  feculent  and  assume  a  more  brownish 
appearance.  The  reaction  is  usually  acid.  Micro.scopic- 
ally  they  show  an  abundance  of  mucus,  a  large  amount 
of  intestinal  epithelium,  and  a  large  number  of  acidophilic 
bacilli,  which  stain  by  Gram's  method  in  contradistinction 
to  the  normal  intestinal  bacteria,  which  react  negatively 
to  Gram's  stain. 

CHOLERA   INFANTUM 

Cholera  infantum  is  a  very  acute  condition  accomy)anied 
by  the  .symptoms  of  severe  collapse,  vomiting,  and  diar- 
rhea, brought  on  by  the  ingestion  of  milk  which  has 
undergone  ectogenic  degeneration  on  account  of  preserva- 
tion in  too  high  a  temperature  (Escherich).  It  occurs 
most  frequently  in  the  summer  months,  infants  between 
five  and  seven  months  of  age  are  most  prone  to  develop 


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INTESTINAL  INFLAMMATIONS  363 

it,  and  that,  too,  of  a  severe  type  (Schlossmann).  In 
the  majority  of  cases  death  occurs  in  from  one  to  six 
days  in  consequence  of  excessive  loss  of  water  and  severe 
intoxication  (the  heart  weakens,  acute  course,  cyanosis ; 
later,  sclerema  and  hydrocephalus). 

A  most  unfavorable  prognostic  sign  is  the  vomiting  of 
coffee-ground  masses  (blood). 

Stools. — Greenish-yellow,  watery  stools,  throughout 
which  are  interspersed  colorless  flakes  of  mucus.  In 
some  cases  they  consist  only  of  a  colorless  and  odorless 
liquid.     Alkaline  reaction. 


INTESTINAL  INFLAMMATIONS 

Intestinal  inflammations  are  diseases  of  the  intestines 
which  follow  catarrhal  and  dyspeptic  processes,  or  they 
may  be  primary. 

Morbid  Anatomy. — Swelling,  inflammation,  and,  finally, 
suppuration  and  ulceration.  Swelling  of  tiie  mesenteric 
and  inguinal  glands. 

The  stools  are  considerably  increased  in  number  and 
contain  mucus,  blood,  and  pus.  If  only  isolated  portions 
of  the  intestines  are  involved,  practically  normal  stools 
may  be  passed  alternating  with  those  of  a  pathologic  na- 
ture. As  a  result  of  the  excessive  watery  discharges  per 
rectum,  the  secretion  of  urine  is  diminished  and  the 
thirst  increased.  If  gastric  catarrh  or  edema  of  the  cere- 
bral meninges  is  also  present,  vomiting  develops.  Symp- 
toms of  cerebral  irritation  are  frequently  present.  The 
loss  of  body  juices,  loss  of  sleep,  and  si)reading  of  the 
infection  leads  to  a  rapid  decline.  Complete  cure  does 
not  occur  even  in  favorable  cases  until  after  several 
weeks. 

Sequelae. — Thrush  is  favored  by  constitutional  weak- 
ness ;  intertrigo  is  due  to  the  irritation  of  the  frecpient 
stools  and  the  concentrated  urine;  metastatico-septic  proc- 
esses are  also  met  with.  Secondary  infections  include 
ecthyma,  furunculosis,  pidegmasia,  ])neumonia,  otitis,  cy.s- 
titis,  nephritis,  and  pyelonephritis. 


364  G ASTRO-INTESTINAL  DISEASES 

PLATE  39 

Prolapsus  recti  of  a  moderate  degree,  duu  to  straining  and  pressing 
during  evacuation'  of  the  bowels.  Secondary  erythema  of  the  nates. 
(Clinic  of  Escherich,  Vienna.) 


Otlier  forms  of  intestinal  inflammation  to  be  consid- 
ered are  : 

Gastroenteritis,  which  usually  represents  only  an  ex- 
acerbation of  dyspeptic  or  catarrhal  diseas^e,  is  especially 
likely  to  attack  the  small  intestine.  Not  until  a  later 
stage  is  the  large  intestine  involved. 

The  copious  stools  are  watery  and  discharged  in  spurts  ; 
and  contain  at  the  beginning  only  remnants  of  food,  but 
consist  later  of  an  odorless  or  foul-smelling  green  or  gray- 
ish-yellow mucoid  fluid,  with  which  are  mixed  blood  and 
pus.  The  reaction  is  usually  alkaline.  The  abdomen  is 
frequently  distended  and  tense,  but  the  umbilicus  not  ob- 
literated. 

Colitis,  a  ])rimarily  localized  inflammation  of  the  large 
intestine,  is  frequently  an  expression  of  a  true  intestinal 
infection  which  develops  at  times  in  limited  epidemics 
(Widerhofer's  follicular  enteritis).  The  discharges  con- 
tain colon-like  bacilli  (Rossi,  Finkel.<tein,  Esclierich, 
Celli),  and  more  recently  dysenteric  bacilli  of  the  Shiga- 
Kruse  as  well  as  of  the  Flexner  type  were  found  by 
American  authors  and  Jehle  (clinic  of  Escherich).  Ac- 
cordingly this  disease  seems  to  bear  a  close  etiologic  rela- 
tionship to  epidemic  dysentery  ("  colitis  dysenteriformis," 
Concetti). 

The  (li.sea.se  always  has  an  acute  onset  and  is  usually 
accompanied  by  a  high  irregidar  and  remittent  fever. 
The  general  health  is  unfavorably  influenced  by  colic, 
troublesome  tenesmus,  and  sleeplessness,  and  the  symp- 
toms of  collapse  set  in  rapidly.  The  abdomen  is  retracted 
and  the  thickened  descending  colon  may  be  paljiated  as  a 
sausage-shaped  tumor  which  is  tender  upon  pressure. 
Prolapsus  recti  develops  frequently,  owing  to  straining 
and  ])ressing  during  stools. 

The  stooh,  which  are  accompanied  by  tenesmus,  consist 


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CHRONIC  AFFECTIONS  365 

exclusively  of  a  little  serous  fluid  and  bile-stained  gelati- 
nous or  colorless  frog-spawn-like  mucus,  which  is  inter- 
mingled with  more  or  less  pus  and  fresh  red  blood  in 
traces  or  in  large  amounts.  The  number  of  stools  is 
enormous,  sometimes  as  many  as  forty  or  fifty  are  jmssed 
per  day.  The  amount  of  each  discharge  at  the  beginning 
lis  considerable,  but  rapidly  lessens,  so  that  finally  only  a 
small  trace  of  mucus  sprinkled  with  blood  appears.  The 
reaction  is  alkaline  and  the  odor  at  the  beginning  is  stale  ; 
later,  however,  when  putrefaction  of  the  albumin-contain- 
ing intestinal  secretion  sets  in,  it  becomes  foul. 

CHRONIC  AFFECTIONS 

Chronic  affections  frequently  follow  the  foregoing  con- 
ditions, but  at  times  they  are  caused  by  the  continued 
action  of  injurious  factors  (errors  in  diet  and  unhygienic 
dwellings).  The  mucous  membrane  of  the  intestines  is 
frequently  catarrhal,  relaxed,  and  anemic  throughout  its 
whole  extent,  or  it  shows  residue  of  a  preceding  inflam- 
mation. The  follicles,  Peyer's  patches,  and  mesenteric 
glands  are  swollen.  As  an  acute  form  of  intestinal  in- 
flammation passes  into  the  chronic  stage  all  of  the  violent 
symptoms  disappear  without  recovery.  Accompanied  by 
intervals  of  exacerbation  and  temporary  improvement  the 
course  may  stretch  over  several  months,  with  resulting 
marked  emaciation  and  loss  of  strength.  The  prospects 
for  recovery  lessen  with  the  duration  of  the  disease.  The 
stools  are  discharged  at  irregular  intervals  and  vary 
considerably  in  quality  and  quantity.  The  abdomen  is 
often  distended  as  a  result  of  fermentation  and  putre- 
factive processes  in  the  intestines,  yet  it  is  nevertheless 
soft,  and  the  umbilicus  is  not  obliterated.  The  appetite 
varies  and  vomiting  occurs  occasionally.  Development 
of  thrush  is  a  frequent  occurrence.  Fever  arises  only 
when  complications  set  in.  Furthermore,  we  note  all  the 
results  of  disturbed  absorption  and  nourishment  and  the 
loss  of  body  juices  ;  these  include  anemia,  emaciation,  and 
fatty  degeneration  of  the  organs — atrophia  infantum. 


366  GASTRO-INTESTINAL  DISEASES 

ATROPHIA  INFANTUM 

(Pedatrophia) 

Atrophia  infantum  represents  a  general  wasting  disease 
which  arises  whenever,  for  any  reason,  the  digestive,  the 
absorptive,  and  the  assimilative  power  become  inefficient 
Pedatrophia  may  accordingly  develop  as  a  sequel  to  a 
previous  acute  gastric  catarrh,  or  primarily  in  congenital 
weakness  of  the  digestive  function,  or  in  improper  feed- 
ing, in  which  cases  the  gastro-intestinal  diseases  are  not 
the  cause  but  the  result  of  this  condition  (Eschericii,  Con- 
cetti). Since  the  digestive  apparatus  works  at  a  great 
loss,  the  amount  of  absorbed  and  assimilated  nutriment 


Fig.  118. — Pedatrophia.  Five-raonth's-old  child  which  emaciated  to  a 
skeleton  from  gastro-intestinal  disease  (weight,  3350  gni.).  Movements 
of  defense  were  barely  noticeable  (spasmodic  seizures  of  the  extremities) ; 
the  skin  is  of  a  dirty  color,  dry,  sallow,  andean  be  lifted  in  folds.  Pan- 
niculus  adiposus  almost  completely  disappeared.  Tiie  face  presents  a 
wizened  expression.  The  abdomen  is  retracted  and  soft.  Thrush. 
Intertrigo  of  gluteal  region. 

necessary  to  meet  the  requirements  of  nutrition  are 
no  longer  satisfied.  The  organism  receives  sparse  and 
insufficient  compensation  for  the  body  material  consumed, 
at  any  rate  not  the  supply  necessary  for  body  growth. 
The  body  is  finally  com|)elled  to  attack  the  supply  of 
energy  daily  necessary  to  life  which  is  preserved  in  its  fat 
deposits — /.  e.,  it  gradually  wastes  away  (Heubner).  If 
this  disturbance  of  metabolism  continues  for  a  long  period 
of  time  the  following  series  of  .symptoms  arise  in  the  order 
they  are  given,  which  may,  however,  vary :  Emaciation, 
loss  of  vital  activity  of  the  organs,  and  therefore  height- 


ATROPHIA  INFANTUM  867 

ened  predisposition  to  secondary  diseases  of  the  skin,  the 
mucous  membranes,  the  lungs,  the  kidneys,  and  of  the 
nervous  system;  gradual  starvation  and,  finally, death. 

Stools. — These  depend  upon  the  origin  of  the  chronic 
aifection,  and  in  some  cases  hardly  differ  from  the  normal 
(so  in  primary  atrophy),  wjiereas  in  other  cases  are  noted 
the  characteristic  dyspeptic,  catarrhal,  and  enteritic  stools 
which  rapidly  alternate  with  each  other.  During  the 
final  stage  they  are  brownish,  homogeneous,  and  soup-like. 

Prophylaxis  of  G-astro-intestinal  Diseases. — An  attempt 
should  be  made  to  prevent  the  development  of  gastro- 
intestinal diseases  whenever  possible  by  providing  the 
infant  with  natural  nourishment,  that  is,  the  mother's 
breast  milk,  otherwise  a  proper  substitute  for  it  by  means 
of  fresh  cows'  milk,  which  is  secured  in  clean  stalls  and 
prepared  according  to  accepted  scientific  methods.  Pro- 
tect the  child  from  overfeeding  or  insufficient  feeding,  and 
observe  the  rule  that  the  amount  of  food  administered 
equals  in  the  first  quarter  year  one-sixth,  in  the  second 
quarter,  one-seventh,  in  the  third  quarter,  one-eighth  of  the 
body  weight.  (See  Nutrition,  p.  42.)  Weekly  determi- 
nation of  the  body  weight  by  means  of  scales  is  impor- 
tant. We  should  inform  ourselves  accurately  as  to  every 
detail  of  nursing,  ventilation,  light,  warmth,  rest,  and 
cleanliness  (also  as  to  the  personality  of  the  nurse).  In- 
testinal infection  and  sepsis  may  be  easily  prevented  in 
private  practice  by  observation  of  the  simplest  hygienic 
principles.  Wherever  a  large  number  of  infants  and 
younger  children  must  live  in  a  single  room,  as  in  chil- 
dren's hospitals  or  orphan  asylums,  the  above-mentioned 
conditions  are  more  likely  to  occur,  and  for  their  preven- 
tion far  more  energetic  and  expensive  measures  must  be 
undertaken.  A  glance  at  Fig.  119  shows  how  in  modern 
times  it  is  possible,  and  with  excellent  results,  to  i>revent 
infection  by  contact  by  means  of  the  Heubner,  Finkel- 
stein,  Schlossmann,  and  other  maternity  hospitals.  The 
individual  beds  are  isolated  by  glass  walls  ("boxes,"  par- 
tially open  cells).  The  material  necessary  for  the  nurs- 
ing of  each  individual  child  is  usually  kept  prepared  in 


368 


GASTROINTESTINAL  DISEASES 


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ATROPHIA   INFANTUM  369 

the  same  enclosed  room  (individual  drinking,  washing, 
bathing,  and  night  utensils,  individual  thermometers  and 
other  instrumentarium,  and  individual  examination  coat 
for  the  physician,  etc). 

The  treatment  of  gastro-intestinal  diseases  is  causal, 
and  it  is,  therefore,  necessary  to  remove  the  etiologic  fac- 
tor. In  the  first  place  the  protective  functions  of  the 
body  must  be  supported.  The  organism  seeks  in  the  va- 
rious dyspeptic,  catarrhal,  and  inflammatory  aifections  to 
discharge  injin-ious  ingesta  from  the  stomach  and  intes- 
tines by  means  of  vomiting,  increased  intestinal  excretion, 
and  by  peristalsis.  We  assist  nature  in  recent  and  acute 
cases  by  cleansing  the  stomach  and  colon  and  by  means 
of  lavage,'  and  the  small  intestine  by  the  administration 
of  castor  oil  (|  coffeespoonful  every  two  hours). 

Secondly,  as  nature  requires  rest  for  the  diseased  organ, 
anorexia  sets  in.  Accordingly,  therefore,  depending  upon 
the  severity  of  the  case,  food  is  given  only  at  intervals 
varying  between  six  and  forty-eight  hours  (in  cholera  in- 
fantum intervals  of  several  days);  on  the  other  hand,  the 
increased  demand  for  liquids  should  be  satisfied  after  one- 
half-  to  two-hour  pauses  with  smaller  or  larger  amounts 
of  weakly  sweetened  cold  teas  or  alkaline  mineral  waters 
(Schlossmann). 

'  Gastric.  Ldvarje. — Tlie  instrumentarium  consists  of  a  Nilaton  cath- 
eter (No.  18  to  20),  a  50-cm.  [20-in.]  long  rubber  tube  (both  united  by 
means  of  a  glass  tube),  and  a  glass  funnel  having  a  capacity  of  30  ccni. 
[1  fl.  oz.].  The  child  lies  with  its  hips  i-aised  upon  its  mother's  lap,  who 
rests  her  rigiit  foot  upon  a  footstool  and  the  left  foot  upon  the  Hoor.  The 
physician  introduces  the  Nelaton  catheter  by  exerting  light  downwanl 
pressure  upon  the  tongue,  and  passes  it  for  2.'>  cm.  [10  in.]  into  the 
esophagus  (the  alveolar  Ixirder  is  lo  to  23  cm.  [fi-0.4  in.]  distant  from 
the  cardia  at  the  age  of  one  year),  .\fter  the  gastric  contents  have 
been  removed  the  stomach  is  washed  clean  with  a  .6  per  cent,  sodium 
chlorid  solution  at  a  body  temperature. 

Inlexlinnl  Lrmu/e. — InstrumenUiriinu  the  same  as  above,  but  in  place 
of  the  Nelaton  catheter  an  intestinal  tulx>,  1  meter  [32  in.]  long,  and  in 
place  of  the  funnel,  a  gi-aduatwl  irrigator,  are  employed.  The  child  lies, 
with  its  pelvis  raised,  (m  its  side  or  on  its  abdomen.  The  lubricated  in- 
testinal t!ibe  is  introduced  with  a  gentle  pushing  movement  to  such  a 
height  in  high  encniata  that  the  fluid  will  ag;iin  pass  out  beside  the  tulie. 
The  length  of  the  large  intestine  during  the  first  year  of  life  is  50  to  100 
cm  [20-40  in.]. 
24 


370  G ASTRO-INTESTINAL  DISEASES 

Thirdly,  we  must  bear  in  mind,  wlicn  normal  feeding  is 
again  resorted  to,  that  the  functional  activity  of  the  di- 
gestive apparatus  has  become  limited  by  the  effects  of  the 


Fig.  120.— Gastric  lavage  in  iufauts. 

foregoing  diseases  and,  therefore,  only  a  very  small  amount 
of  nourishment  should  be  given  at  the  beginning.  Ac- 
cordingly, only  minute  quantities  of  food  are  given  after 


ATROPHIA   INFANTUM  371 

as  long  intervals  of  time  as  possible.  During  the  inter- 
vals administer  tea  or  mineral  water  to  satisfy  thirst. 

In  the  regulation  of  diet  we  must  next  consider 
whether  the  aifection  concerned  is  associated  with  acid  or 
alkaline  fermentation  (albuminous  puti'efaction).  In  the 
first  case  the  diet  is  begun  with  egg-albumin-water,  thin 
boiled  rice,  and  rolled  oats;  later,  veal  broth  may  be 
given.  In  the  case  of  albuminous  putrefaction  {e.g.,  pu- 
trefaction of  the  intestinal  secretions)  give  a  carboiiydrate 
diet  (Soxhlet's  nutritive  sugar,  infants'  foods)  or  weak 
cream  mixtures.  After  recovery  sets  in  resort  is  again 
had  to  simple,  fresh-milk  nourishment.  In  cholera 
infantum  the  supply  of  liquid  necessary  for  life  is  main- 
tained by  subcutaneous  infusion  of  normal  salt  solu- 
tion/ and  when  it  is  possible  to  agtiin  take  liquids 
per  OS  they  must  be  administered  at  first  in  very  minute 
quantities. 

It  is  of  the  greatest  importance  in  pedatrophy  to  obtain 
a  diet  which  requires  the  least  amount  of  digestive  energy, 
and  which  will  be  more  easily  assimilable  than  the  pre- 
vious form  of  nourishment.  Aside  from  women's  milk, 
the  looked-for  results  have  been  attained  in  mild  cases  by 
the  use  of  buttermilk  (Texeira  de  Mattos)  or  cream  mix- 
tures. 

Medication  is  of  little  use  in  the  treatment  of  gastro- 
intestinal disease  in  infants.  Castor  oil  is  generally  indi- 
cated in  the  first  stages  ;  tannin  and  bismuth  preparations 
are  often  very  efficient  in  profuse  intestinal  secretion  (tan- 
nigen  or  tannalbin,  0.25  gm.,  every  two  or  three  hours, 
bismuth  subnitrate  or  bismuth  salicylate  in  emulsion,  2.0 
or  5.0  gm.  :  100.0,  in  coffeespoonfnl  doses  every  two  or 
three  hours).  Drop  doses  of  opium  (careful  dosage)  in 
starch  enemata  relieve  pain  and  give  rest  in  severe  enter- 
itis.    In  other  respects  the  use  of  drugs  is  often  useless. 

1  Infusion  of  100  to  150  ccni.,  twice  daily,  of  a  sterilized,  physiologic 
salt  solution  at  bodv  temperature;  or  a  solution  of  sodium  hicnrbonate 
3.0  gm,  and  sodiun"i  ohlorid  4.0  gm. :  1000.  The  solution  is  intro<luoe<i 
underneath  the  alnlominal  skin  bv  means  of  a  curved  infusion  netnlle,  a 
tube,  and  funnel,  or  it  is  injected'by  means  of  a  largesyringe.  Massage 
of  the  tumor  caused  by  the  injected  fluid. 


372 


G ASTRO-INTESTINAL  DISEASES 


Treatment  of  Constipation. — If  the  constipation  is  a  re- 
sult of  muscular  weakness  the  symptomatic  use  of  sup- 
positories or  enemata  is  recommended,  also  light  abdom- 
inal massage  to  strengthen  the  musculature.     In  case  the 


Fig.  121. — Abdominal  massage  in  infants.  I  Massage  of  the  descend- 
ing colon.  Rotary  movements  of  the  hand,  with  simultsineous  move- 
ment of  the  abdominal  walls;  pressure  being  increased  in  a  longitudinal 
direction  over  the  colon.  II.  Massage  of  the  ileocecal  region.  (Sameas 
I.)  in.  Massage  of  the  small  intestine.  The  hand  placed  flat  upon  the 
abdomen  in  the  region  of  the  umbilicus  performs  movements  by  i)rona- 
tion  and  supination,  and  pressure  is  e.xerted  upon  the  abdomen  at  one 
time  with  the  tips  of  the  fingers  and  at  another  time  with  the  ball  of  the 
hand.  Finally,  the  center  of  the  abdomen  is  tapped  with  piano-playing- 
like  movements.     IV.  Stroking  the  colon  throughout  the  whole  course. 


constipation  is  due  to  dys])epsia  good  results  can  only  be 
obtained  from  as  thorough  a  ciiange  of  diet  as  is  po.ssible. 
If  it  be  due  to  spastic  conditions  small  doses  of  opium 
frequently  act  very  promptly.     Rhagades  of  the  anus  re- 


ATMOPHIA  INFANTUM  373 

quire  applications  with  the  silver  stick.  In  enlarged 
colon  (Hirschsprung's  disease)  complete  cure  may  be  ob- 
tained by  means  of  methodic  introduction  of  oil. 

Treatment  of  Prolapsus  Recti. — In  Mild  Cases. — Adhe- 
sive straps  placed   like  tiles  over  the  nates,  which  are 


Fig.  122.— Adhesive-plaster  dressing  for  prolapsus  recti. 

tightly  pressed  together.     The  plaster  must  extend  over 
the  perineum. 

In  Severe  Cases. — Fixation  of  the  rectum  by  means  of 
longitudinally  directed  injections  of  paraffin.  This  is 
]>erforniod  according  to  the  method  described  by  Spitzy 
(Children's  Clinic  at  Graz) :  Melted  hard   jiaraffin  (melt- 


374  GASTRO-INTESTINAL  DISEASES 

ing-point  50°  to  55°  C.  [122°-131°  F.])  is  drawn  into  a 
sterilized  and  heated  syringe,  which  is  covered  with  a 
rubber  tube  to  prevent  the  rapid  dissipation  of  heat,  and 
suj)plied  with  a  straight,  not  too  narrow,  hollow  needle 
which  measures  8  to  12  cm.  [3.4-4.8  in.]  in  length.  The 
needle  is  inserted  between  the  coccyx  and  rectum  ;  the 
left  index-finger  is  introduced  into  the  rectum  and  guides 
the  syringe  as  high  up  as  possible.  While  the  needle  is 
slowly  withdrawn  about  5  ccm.  of  the  paraffin  are  in- 
jected. The  injected  material  hardens  rapidly  and  when 
cooled  forms  an  irregular  longitudinal  ridge  which  per- 
manently prevents  inversion  of  the  rectum  without  caus- 
ing any  constipation.  When  carefully  performed  one 
injection  is  sufficient.  Ill  results  are  not  noticed.  The 
effect  is  more  certain  in  action  and  less  formidable  than 
the  methods  formerly  practised. 

ATONY  OF  THE  STOMACH  AND  INTESTINES 

Atony  of  various  sections  of  the  digestive  tract  are  of 
great  practical  interest.  In  the  stomach  such  a  contlition 
is  represented  by  gastric  paresis  (usually  due  to  overfeed- 
ing or  improper  feeding,  and  is  acquired  during  the  first 
year  of  life — Pfaundler),  In  the  intestines,  where  it  is 
known  as  "  intestinal  atony,"  this  condition  plays  an  im- 
portant role  in  the  digestive  disturbances  of  childluKxl. 
Anemic  and  weak  girls  who  are  apjiroaching  puberty 
are  esjKicially  likely  to  suffer  frequently  from  anorexia 
and  obstinate  constipation.  The  latter  may  be  accom- 
panied by  a  whole  series  of  toxic  and  nervous  symptoms 
(migraine,  periodic  vomiting,  intermittent  albuminuria, 
arhythmia  of  the  pulse,  and  skin  eruptions). 

Treatment. — Scientific  massage  of  the  abdomen,  certain 
exercises  (performed  on  home  gymnastic  appliances), 
moist  applications  and  douches  upon  the  abdomen,  fara- 
dization of  the  atonic  portions  of  the  intestines  ;  later, 
baths  and  a  vegetable  diet.  The  abuse  of  purgatives  is 
to  be  guarded  against.  Gastric  paresis  in  infants  responds 
rapidly  and  favorably  to  limitation  of  diet  and  intervals 


CONGENITAL  STENOSES  AND  ATRESIA        375 

between  feeding.  In  obstinate  cases  the  gastric  contents 
present  after  two  and  a  half  hours  should  be  removed 
systematically  (without  lavage). 

APPENDICITIS 

Disease  of  the  appendix  and  its  vicinity  in  children 
is  practically  analogous  to  that  in  adults.  However, 
greater  difficulty  in  diagnosis  is  frequently  met  with  in 
childhood.  Of  assistance  in  the  diagnosis  are :  The  re- 
sults of  a  bimanual  examination  by  way  of  the  rectum 
and  the  abdominal  wall  (painful  tumors  in  Douglas' 
pouch)  ;  examination  of  the  blood  (leukocytosis  in  pus 
formation);  the  "  facies  abdominalis";  the  constipation 
and  the  detection  of  an  appendiceal  tumor  by  symmetric 
jialpation  and  percussion  of  the  abdomen.  In  typic  cases 
this  tumor  lies  midway  between  the  umbilicus  and  the  an- 
terior superior  spine  of  the  ilium  ;  frequently,  however, 
it  lies  deeper  in  the  pelvis  at  the  fundus  of  the  bladder, 
to  the  right  or  even  to  the  left  of  the  median  line.  In 
such  cases  dysuria,  which  may  lead  to  the  mistaken  diag- 
nosis of  cystitis,  is  a  characteristic  symptom. 

Treatment. — Early  operation  during  the  intervals. 
Treat  the  attack  as  in  adults. 

CONGENITAL  STENOSES  AND  ATRESIAS  OF  THE 
QASTRO=INTESTINAL  TRACT 

Many  fatal  cases  traceable  to  physical  and  digestive 
weaknesses  are  caused  by  stenosis  of  the  pylorus. 

Etiology. — Closure  of  the  pylorus  (incomplete)  may  be 
due  to  acquired  hypertrophy  of  the  muscularis,  more  fre- 
quently, however,' it  is  due"  to  functional  si>asmodic  nar- 
rowing of  the  opening  (Pfaundler).  Spontaneous  im- 
provement and,  finally,  complete  recovery  occur  in  many 
cases  in  spite  of  most  alarming  symptoms,  including  vom- 
iting after  each  meal  and  frightful  loss  of  body  weight. 
Recovery  mav  be  hastened  by  high  enemata  (for  the  ex- 
isting constipation).  Cataplasm  to  the  abdomen  and 
atropin  internally  or  subcutaneously. 


376  G ASTRO-INTESTINAL  DISEASES 

On  the  whole,  the  prognosis  is  unfavorable  in  stenosis 
and  atresia  of  the  intestines,  excepting  atresia  of  the  anus 
(absence  of  communication  between  the  blind  end  of  the 
large  intestine  and  the  external  cuticular  covering),  which 
is  so  favorably  situated  in  many  cases  that  it  can  be  easily 
corrected  by  oj^erative  intervention  (see  Deformities). 
Congenital  constriction  or  obliteration  of  the  intestines  is 
due  to  the  development  of  peritonitis  during  embryonal 


Fig.  123. — Congenital  hypertrophy  of  the  pylorns.  Enlarged  30 
times.  Thechild  presented  since  birth  the  following  symptoms  of  pyloric 
stenosis  :  Vomiting  always  after  the  ingestion  of  food ;  dimiuisijcd  stools 
and  excretion  of  urine  ;  protruding  and  peristaltic  contractures  of  the 
dilated  stomach;  finally,  a  small  growth  wiis  palpable  in  the  region  of 
the  pylorus.  Temporary  improvement  followed.  Pegniu  milk  and  ex- 
tract of  belladonna.  Gastric  lavage  was  useless.  Death  occurred  in  four 
weeks  due  to  inanition.  Post-mortem  examination  showed  circular 
thickening  and  hardening  of  the  pylorus,  whose  lumen  was  about  3  mm. 
[i  in.]  in  diameter.  1.  Mucosa.  2.  Submucosa.  3.  Hypertrophy  of 
the  muscularis. 

life,  also  twisting  and  strangulation  of  the  intestines 
(Epstein),  as  well  as  volvulus  (Kohts)  in  a  congenital  ab- 
normally long  colon.  This  defect  develops  most  com- 
monly in  the  duodenum,  at  the  end  of  the  ileum,  and 
where  the  descending  colon  jiasses  into  the  S  loop.  In 
atresia,  continuous  vomiting  (of  food,  bile,  and  blood)  sets 
in  as  early  as  the  first  day  of  extra-uterine  life,  followed 
by  death.  In  ])ermeable  stenoses  the  term  of  life  de- 
pends upon  the  degree  of  constriction.     Dilatation  of  the 


CONGENITAL  STENOSES  AND  ATRESIA        377 


Upper  third 
of  the  (111 
denuiii. 


Location  of 
tlie  atresift 
in  tiic-  fliir- 
siil  wall  of 
the  duude- 

lUlUl. 


Pylorus, 


Aaeending 
colon. 


Fig.  124. — Congenital  infrapapillary  atresia  of  the  duodenum.  Twin 
child  four  days  old.  Premature  birth  (seven  and  a  half  months).  After 
birth  the  child  liad  two  pas.sages  of  traces  of  meconium,  since  then  no 
stool.  Nutrition  decidedly  disturbed  ;  bloody  discharge  from  the  nose. 
Icterus,  sclerema,  lobular  pneumonia.  Albuminuria.  Death  fourteen 
hours  after  consultation.  Xecrops;/. — Abdominal  cavity  :  Enormous  diia- 
tjition  of  tlie  stomach  .and  n|)per  duodenum  ;  a  ring-shaped  constriction 
between  the  two  (pyloric  valve).  The  middle  section  of  the  duodenum 
is  converted  intoa  white,  fibrous,  solid  cord,  in  the  U|)per  end  of  whidi 
the  papilla  of  Vater  projects  into  the  duodenum,  whicli  is  here  barely 
open.  From  this  point  a  probe  may  be  easily  pa,s,sed  through  tlie  common 
duct  and  that  of  Wirsung.  From  the  point  of  constriction  downward 
the  intestine  is  completely  collapsed  and  empty. 


378 


G ASTRO-INTESTINAL  DISEASES 


Figs.  125,  126. — Congenital  gastric  and  intestinal  stenosis  and  congcn- 
itsil  displiicenient  of  the  colon  in  an  infant  five  montlis  old.  The  abdo- 
men was  markedly  distended  since  birth;  vomiting;  meconium  was 
passed  only  after  intestinal  lavage.  Breast  fed.  Curdled  milk  was,  not 
passed  until  the  tenth  day  and  then  only  after  lavage.  About  every  four 
weeks  spontaneous,  at  first  diarrheic  and  then  gruel-like  formed,  stools 
were  noted,  and  in  the  course  of  a  few  days  the  obstinate  constipation 
was  renewed,  with  vomiting  at  intervals.  The  spontaneous  stools  were 
preceded  for  several  hours  by  violent  pain.  In  the  performance  of  in- 
testinal lavage  the  tube  met  an  nnsnrmonntable  obstruction  about  22  cm. 
[8.8  in.]  above  the  anus.  Careful  general  and  local  treatment  managed 
to  keep  the  child  in  a  fffirly  good  state  of  nourishment  for  four  weok.s, 
but  after  that  the  health  began  to  steadily  fail.  The  child,  who  had  be- 
come extremely  weak  through  chronic  inanition,  died  in  five  months 


CONGENITAL  STENOSES  AND  ATRESIA        379 


Fig.  126.— (See  description  under  Fig.  125.) 

intestine  above  the  stenotic  area  always  sets  in  primarily ; 
later,  hypertrophy  of  the  musculature  and,  finally,  paral- 
ysis of  the  latter  and  perforative  peritonitis  develop. 
The  clinical  symptoms  are  obstinate  in  spite  of  all  treat- 
ment directed  to  the  constipation,  and  death  occurs  often 
surprisingly  quick  under  the  symptoms  of  peritonitis  or 
intercurrent  diseases.     Laparotomy  may  be  attempted. 


from  acute  enteritis.  Necropsy.— Abdomen  :  No  signs  of  peritonitis. 
The  colon  was  abnormally  elongated  and  presented  an  abnormal  course  ; 
at  first  it  extended  downward  into  the  true  pelvis  and  then,  with  a  double 
loop,  it  passed  laterally  toward  the  right  pelvic  crest  and  upward.  It 
stretched,  markedly  distended,  in  a  uniform  curvature  from  right  to  left 
along  the  lower  border  of  the  thorax  and  pushed  the  liver  backward  and 
do^ynward,  the  stomach  backward  and  upward,  and  made  a  semirotation 
on  its  long  axis.  Where  the  colon  passes  into  the  S  flexure  it  was  fixed 
by  a  peritoneal  covering,  and  decidedly  constricted  by  a  complete  turning 
on  its  axis.  In  the  region  of  constriction  the  folds  of  half  of  the  circum- 
ference of  the  intestines  were  arranged  longitudinally.  The  pylorus 
was  almost  vertical  in  position  :  the  stomach  was  elongated  and  constricted 
in  two  places  :  Directly  before  it  enters  the  dnodenum  ;  at  the  border  be- 
tween the  ventricle  and  the  pylorus,  especially  upon  the  side  of  the  great- 
est curvature.  In  con.seqnence  of  these  stenoses  the  fundus  of  the 
stomach  was  prematurely  developed  ;  the  musculature  was  hypertrophied, 
and  especially  so  at  the  stenotic  areas.  The  three  divisions  of  the  stom- 
ach may  be  easily  recognized — -fundus,  body,  and  pylorus. 


380  GASTROINTESTINAL  DISEASES 

INTESTINAL  INVAGINATION 

Invagination  of  the  intestines  is  rather  frequently  ob- 
served in  children,  especially  during  the  first  year  of  life. 
It  consists  in  the  invagination  of  a  contracted  section  of 
the  intestines  into  a  neighboring  relaxed  portion ;  the 
cause  is  unknown.  The  ileocecal  region  represents  the 
site  of  predilection. 

Symptoms. — ^The  cardinal  symptoms  of  this  constantly 
serious  disease  are:  Constipation;  vomiting;  passage  of 
blood  and  collapse.  The  intussusceptum  is  frequently 
palpable  as  a  movable  hard  tumor  in  the  left  and,  less 
rarely,  in  the  right  side  of  the  abdomen.  The  child 
usually  dies  from  peritonitis.  Spontaneous  resolution  oc- 
curs occasionally  and,  rarely,  recovery  follows  sloughing 
of  the  necrosed  intussusce})tum.  The  so-called  offonal 
invagination,  which  is  frequently  found  accidentally  at 
necropsy,  is  of  no  significance  clinically. 

INTESTINAL  PARASITES 

Parasites,  such  as  oxyuris,  ascarides,  and  tenia,  are 
found  in  the  intestinal  tracts  of  about  40  per  cent,  of  all 
children.  The  general  health  is  often  not  disturbed  by 
them  for  a  long  time,  but  at  times  we  note  abdominal 
pain,  nausea,  vomiting,  itching  of  the  nose  and  anus,  and 
convulsions.  If  the  condition  persists  for  a  long  time, 
anemia  and  nervous  irritability  arise. 

The  diagnosis  is  determined  by  the  discharge  of  para- 
sites, or  sections  of  thera,  or  by  the  microscopic  detection 
of  their  eggs. 

The  Oxyuris  vermicularis,  the  thread-  or  spring-worm, 
is  whitish  yellow  in  color,  spindle  shaped,  and  measures 
from  3  to  10  mm.  [1— i  in.]  in  length  and  0.5  mm. 
[sV  '"•]  '"  thickness.  Its  eg^s  have  thin  walls,  oval  in 
shape  or  flattened  at  the  sides.  The  female  deposits  its 
eggs  in  the  folds  of  the  anus,  which  produce  an  itching 
that  requires  constant  scratching  ;  through  the  latter  the 
fingers  become  infected  with   the  eggs.     This,  leading  to 


INTESTINAL  PARASITES  381 

autoreinfection,  causes  the  oxyuriasis  to  become  an  ex- 
tremely persistent  disease. 

The  treatment,  therefore,  consists,  in  the  first  place,  of 
absolute  cleanliness  of  the  anal  region  and  the  prevention 
of  scratching.  Give  enemata  of  thymol  or  1  coffee- 
spoonful  three  times  a  day  of  santonin  with  castor  oil, 
0.2:  60.0;  or,  better,  0.15  to  0.4  gm.  of  naphtalin  in' 
eight  doses  during  two  days,  to  l)e  repeated  after  an  inter- 
val of  from  one  to  two  weeks  (strangury)  [Ungarj. 

The  Ascaris  lumbricoides,  or  round- worm,  is  grayish 
yellow  or  grayish  red  in  color,  measures  20  to  40  cm. 
[8-16  in.]  in  length,  0.5  cm.  [0.2  in.]  in  width,  and  is 
pointed  at  the  extremities.  Its  eggs  show  dark  granules 
and  have  a  thick  concentrically  striped  membrane.  The 
entrance  of  this  parasite  into  the  common  duct,  the  pan- 
creatic duct,  or  the  appendix  may  excite  an  obstinate 
icterus  and  other  inflammatory  phenomena. 

Treatment. — Trochisci  of  santonin  or  castor  oil  with 
santonin  (0.2  to  0.25  gm.  :  40.0)  in  coffee-  or  tablespoon- 
ful  doses. 

The  Trichocephalus  dispar,  or  whip-worm,  is  yellowish 
white  in  color,  measures  about  2  to  3  cm.  [.8-1.4  in.]  in 
length,  and  is  pointed  at  the  anterior  end,  but  thickened 
at  the  posterior.  It  may  cause  a  large  number  of  enter- 
itic  symptoms. 

Tenia  mediocanellata  is  the  commonest  form  of  taj>e- 
worm  in  children  and  follows  the  ingestion  of  raw  beef. 
It  is  4  or  5  m.  [12  or  15  ft.]  long,  shows  a  fine  dichoto- 
mous  division  of  the  uterus,  and  its  head  is  supplied  with 
four  suckers  and  no  crown  of  hooklets. 

Tenia  solium  develops  in  the  body  from  the  ingestion  of 
raw  pork.  It  is  2  to  3  m.  [6-9  ft.]  in  length,  narrower 
and  thinner  than  Tenia  mediocanellata,  and  its  head  issujv 
plied  with  hooklets.  The  uterus  shows  dendritic  division. 
Treatment. — Freshly  prepared  extract  of  the  male  fern, 
2.0  to  5.0  gm. ;  kamala,  1.5  to  5.0  gm.  ;  flower  of  ku.««.so, 
8.0  to  15.0  gm.;  Kus.sein  "Merck";  Helfenberg's  tape- 
worm remedy  (extract  of  fern  with  castor  oil) ;  extract  of 
pumpkin  seed  given  in  three  doses.     In  young  children 


Fig.  127. — Intestinal  parasites,     a.  Tenia  nn  iita  (head,  seg- 

ments). 6.  Tenia  solium  (head,  segments),  c.  Oxyuris  vermicularis 
(male,  female,  eggs),  d.  Trichocephalus  dispar(male,  egg),  e.  Asearis 
Inmbricoides  (female,  eggs).  (From  Ziegler's  Text-book  of  Goieral  Path- 
ology.) 

382 


CHRONIC  PERITONITIS  383 

administer  the  latter  through  an  esophageal  tube.  Care 
must  be  observed  in  its  use  in  children  before  three  years 
of  age.  The  above  treatment  is  to  be  followed  by  doses 
of  castor  oil.  The  cure  may  only  be  considered  accom- 
plished when  the  head  of  the  tapeworm  has  been  discov- 
ered in  the  stools. 

DISEASES  OF  THE  LIVER 

ICTERUS 

Aside  from  the  physiologic  icterus  neonatoi'um  and  the 
symptomatic  icterus  due  to  septic  infection  in  newborn  in- 
fants, we  also  observe,  but  not  rarely,  jaundice  following 
congenital  defects,  such  as  obliteration  of  the  gall-bladder 
or  bile-ducts.  The  latter  forms  run  a  rapidly  fatal  course 
accompanied  by  symptoms  of  severe  disturbances  of  di- 
gestion and  of  the  general  health.  Catarrhal  icterus  in 
children  is  comparatively  rare  considering  the  frequency 
of  acute  digestive  diseases.  The  course  is  the  same  as  in 
adults. 

DISEASES  OF  THE   PERITONEUM 
ACUTE  PERITONITIS 

Acute  peritonitis  occurs  primarily  in  septic  infection  of 
the  newborn,  also  in  traumatism,  but  it  occurs  far  more 
frequently  secondarily  to  intestinal  ulceration,  jwrityphli- 
tis,  intussusception,  and  certain  infectious  disea.ses,  espe- 
cially typlioid  fever,  dysentery,  scarlet  fever,  etc. 

The  clinical  symptoms  and  the  morbid  anatomy  are 
es.sentially  like  those  of  acute  peritonitis  in  adults. 

The  prognosis  is  comparatively  favorable  in  traumatic 
peritonitis,  but  always  bad  in  the  septic  forms.  The  older 
the  child  the  better  are  the  prospects. 

CHRONIC  PERITONITIS 

Chronic  peritonitis  is  nearly  always  of  a  tub(>rcidous 
nature  (see  Tuberculosis),  yet  undoubted  cases  of  chronic 
peritonitis  are  met  which  are  not  of  such  a  character.     It 


384  DISEASES  OF  THE  PERITONEUM 

is  either  a  terminal  stage  of  acute  peritonitis  or  it  arises 
primarily  following  traumatism,  exposure  to  cold,  or  as  a 
sequel  to  measles.  A  serous  or  serofibrinous  exudate  is 
found  in  the  abdominal  cavity,  also  manifold  adhesions  of 
intestinal  loopsdue  to  inflammatory  foci  in  the  peritoneum, 
as  well  as  thickening  of  the  peritoneal  coat  of  the  in- 
testines and  the  parietal  peritoneum.  The  contracted 
omentum  is  also  thickened. 

Symptoms. — This  disease  leads  to  disturbances  of  nu- 
trition ;  obstinate  constipation  alternates  at  intervals  with 
an  apparently  groundless  diarrhea.  The  child  undergoes 
emaciation,  turns  sallow,  and  the  skin  and  hair  become 
dry,  the  latter  brittle.  The  appetite  and  spirits  show 
great  variations.  The  large  distended  abdomen  presents 
a  marked  contrast  to  the  emaciated  body.  Excepting  an 
uncomfortable  feeling,  subjective  pains  are  rarely  pres- 
ent. 

Prognosis. — The  prognosis  is,  on  the  whole,  favorable. 
A  complete  cure  follows  careful  nursing,  yet  intercurrent 
diseases,  especially  of  the  respiratory  organs,  represent 
serious  complications. 

Diagnosis. — In  reaching  a  conclusion  as  regards  the 
diagnosis  it  is  of  primary  importance  to  exclude  tuber- 
culosis, then  cirrhosis  of  the  liver,  echinococcus,  and  all 
diseases  of  the  heart,  lungs,  and  kidneys  which  are  ac- 
companied by  marked  disturbances  of  circulation,  as  well 
as  diseases  of  the  abdominal  glands  and  other  tumors. 

Treatment. — The  child  must  be  provided  with  the  most 
favorable  hygienic  circtmistances  of  life.  As  much  out- 
door life,  fresh  air,  and  sunshine  as  possible  (observe  care 
in  the  employment  of  sun-baths  as  regards  the  amount  of 
exposure).  A  non-irritating  diet  corresjionding  to  the  age 
and  strength  of  the  patient.  General  massage.  Sys- 
tematic rubbing  with  soft  soap.  Hydrotherapeutic  meas- 
ures according  to  the  circumstances.  Mild  Carlsbad  cure. 
External  and  internal  administration  of  iodin  prepara- 
tions. 


DISEASES  OF  THE  GENITO-URINARY 
TRACT 

DISEASES  OF   THE   KIDNEYS 

GENERAL  DISCUSSION 

The  metabolic  processes  in  the  growing  organism  re- 
quire an  increased  functional  activity  of  the  kidneys,  upon 
which  the  regulation  of  metabolism  chiefly  depends,  hence 
the  increasing  predisposition  of  these  organs  to  disease. 
Only  slight  diiferences  are  exhibited  between  the  indi- 
vicUial  renal  diseases  of  adults  and  children.  However, 
in  adults  we  observe  chronic  renal  disease  following  more 
frequently  chronic  intoxications  and  general  constitutional 
diseases ;  wiiereas  in  children  acute  inflammatory  con- 
ditions predominate,  which  are  chiefly  due  to  infectious 
processes. 

It  is  necessary  in  the  diagnosis  of  renal  disease  to  de- 
pend more  upon  the  examination  of  the  urine  in  chihlren 
tiian  in  adults  because  of  the  absence  or  of  the  insuffi- 
ciency of  subjective  symptoms  and  because  of  the  diffi- 
culty in  reaching  the  kidney  in  the  piiysical  examination 
of  children.  Tlierefore  the  chemic  and  microscopic  ex- 
amination of  the  urine  must  never  be  neglected  in  all 
affections  which  might  cause  nephritis. 

To  obtain  the  urine  in  infants  we  employ  the  apparatus 
recommended  by  Heckcr  (Fig.  128),  which  i)reyents  the 
backward  flow  of  the  urine  from  the  glass  and  is  applic- 
able for  either  male  or  female. 

ALBUMINURIA 

The  presence  of  albumin  in  the  urine  is,  as  a  rule,  in- 
dicative of  pathologic  changes  in  the  kidneys  or  in  the 
deep  urinary  passages.     In  rare  cases,  however,  a  slight 

.)%  385 


386 


DISEASES  OF  THE  KWyEYS 


HEMATURIA    AND  HEMOGLOBIXURIA  387 

immitory  albuminuria  is  met  with  without  demonstrdble 
cause,  especially  after  physical  or  meutal  overexertion, 
after  cold  baths,  and  after  the  ingestion  of  food  contain- 
ing an  overabundance  of  albumin.  Furthermore,  an 
intermittent  (cyclic)  albuminuria  is  occasionally  seen  in 
girls  or  boys  at  the  period  of  puberty,  which  depends 
probably  upon  congenital  renal  weakness  and  which  may 
persist  for  years  without  producing  any  ill  effects.  It  is 
noteworthy  that  this  albuminuria  occurs  only  when  the 
recumbent  is  changed  to  the  erect  posture,  on  account  of 
which  the  albuminuria  of  puberty  is  also  designated  as 
the  orthotic  albuminuria  (Heubner).  This  tyj)e  of  albu- 
minuria is  distinguished  from  that  of  chronic  nephritis 
by  the  absence  in  the  urine  of  casts  and  blood-cells  (Pri- 
bram). In  making  a  diagnosis  it  must  be  borne  in  mind 
that  a  temporary  albuminuria  is  also  produced  by  pollu- 
tion, masturbation,  and  menstruation. 

HEMATURIA  AND  HEMOGLOBINURIA 

Hematuria. — Blood  is  found  in  the  urine  because  of  the 
j)rosence  of  red  blood-cells  in  lithiasis,  hemorrhagic  in- 
flammation of  the  kidneys  or  bladder,  tuberculosis,  hem- 
orrhagic diathesis,  and  after  trauma.  The  blood  may 
therefore  arise  from  various  portions  of  the  urinary 
apparatus.  The  urine,  which  is  strongly  albuminous,  is 
turbid  and  j>ossesses — according  to  the  amount  of  blood 
present — a  color  varying  between  that  of  meat  juice  or 
blackish  red.  In  hemorrhage  from  the  urethra  or  blad- 
der large  blood-clots  are  present,  whereas  in  hemorrhage 
from  the  kidneys  the  blood  can  only  be  demonstrable  mi- 
croscopically and  blood-casts  will  be  present. 

Hemoglobinuria. — In  hemoglobinuria  the  urine  contains 
only  hemoglobin  and  no  red  cells  ;  this  condition  is  noted 
in  Winckel's  disease,  poisoning  with  calciimi  chlorate,  ex- 
tensive burns,  and  occasionally  in  congenital  syphilis, 
scarlet  fever,  and  di]>htheria.  The  urine  is  clear,  of  a 
varnish  color,  similar  to  that  of  M:dag:i  wine,  and  gives 
the  blood  reaction  as  strongly  before  as  after  filtration. 


388  DISEASES  OF  THE  KWyEYS 

Hemoglobinuria  is  sometimes  spasmodic,  in  whicli  ease 
sypliilis  or  a  preceding  attack  of  scarlet  fever  are  at 
fault;  a  similar  condition  at  times  follows  exposure  to 
cold  or  after  physical  fatigue  (paroxysmal  hemoglobinuria). 

ACUTE  PARENCHYMATOUS  NEPHRITIS 

The  most  frequent  of  the  organic  renal  affections  in 
childhood  life  is  acute  diffuse  nephritis.  It,  like  most 
forms  of  nephritis,  is  hematogenic  and  chiefly  toxic-hem- 
atogenic  in  origin,  and  therefore  always  attacks  both  kid- 
neys, usually  to  a  fairly  uniform  extent.  In  the  majority 
of  cases  a  late  action  of  the  virus  of  scarlet  fever  is  con- 
cerned, and  less  frequently  the  action  of  the  diphtheritic 
toxin,  pyogenic  cocci,  and  other  bacteria  and  bacterial 
}K)isons  which  are  c;oncerned  in  the  various  acute  and 
chronic  infectious  diseases.  Poisonous  medicaments  may 
also  excite  inflammatory  irritation  of  the  kidneys  (inter- 
nally, potassium  chlorate,  lead,  and  mercurial  prepara- 
tions ;  externally,  carbolic  acid  and  styrax).  The  rela- 
tionship between  nephritis  with  extensive  inflammations 
and  suppurative  processes  of  the  skin,  intestinal  disease, 
and  colds  is  as  yet  unexplained. 

Morbid  Anatomy. — The  kidneys  in  acute  diffuse  nephritis 
are  enlarged,  hemorrhagic,  and  contain  a  rich  supply  of 
blood,  the  medullary  portion  is  hyperemic,  the  cortex  en- 
larged; in  advanced  cases  they  are  yellowish  gray  or 
speckled,  their  markings  obliterated,  and  their  glomeruli 
are  prominent  as  dark  red  or  gray  granules.  On  micro- 
scopic examination  the  glomeruli  show  epithelial  pro- 
liferation, on  account  of  which  the  loops  of  the  blood- 
vessels are  compressed  or  obliterated,  or  the  phenomena 
of  hemorrhagic  inflammation  are  seen  (necrosis).  The 
dilated  uriniferous  tubules  show  cloudy  swelling,  fatly 
degeneration,  and  desquamation  of  the  epithelium,  con- 
taining blood-cells  and  coagulated  masses  of  albumin 
(casts).  The  interstitial  tissue  presents  inflammatory 
changes  in  the  blood-vessels  and  foci  of  round-cell  in- 
filtration. 


ACUTE  PARENCHYMATOUS  NEPHRITIS        389 

It  is  noteworthy,  dcpciKling  upon  the  nature,  the  in- 
tensity, and' duration  of  the  injurious  factor,  that  in  one 
case  a  certain  tissue  element,  while  in  another  a  different 
element,  is  attacked  with  especial  severity.  Thus,  in 
scarlet  fever,  changes  in  the  blood-vesselsj^  particularly 
of  the  glomeruli,  predominate,  while  in  diphtheria  the 
epithelium  of  the  uriniferous  tubules  is  most  markedly 
involved,  and  processes  of  a  septic  nature  are  mainly 
characterized  by  inflammatory  foci  in  the  interstitial 
tissues  (Heubner). 

Symptoms. — Symptoms  referable  to  nephritis  are  a  result 
of  a  disturbance  of  circulation  interfering  with  the  func- 
tional activity  of  the  kidneys,  which  in  mild  cases,  how- 
ever, are  overshadowed  by  the  symptoms  of  the  primary 
disease.  They  are  frequently  limited  to  a  moderate  fever, 
gastric  phenomena,  moderate  edema  of  the  face  and 
knuckles,  and  the  characteristic  findings  in  the  urine. 
The  amount  of  urine  is  diminished.  It  is  discharged 
after  much  straining  in  small  quantities,  is  cloudy,  dark, 
and,  on  account  of  the  admixture  of  blood,  either  of  a 
meat-juice  color,  brownish  red,  or  blackish.  The  reaction 
is  acid,  the  specific  gravity  high,  and  it  always  contains 
albumin,  blood-cells,  and  an  abundance  of  casts  (granular, 
hyaline,  epithelial,  and  blood-casts),  renal  epithelium,  and 
fatty  d(!tritus. 

The  less  common  serious  forms  are  accompanied  bv 
chills  and  a  fever  as  high  as  40°  C,  [104°  F.],  headache, 
vomiting,  severe  pain  in  the  renal  region,  oliguria  vary- 
ing in  amount  from  150  to  100  ccm.,  and  even  ainiria, 
edema  of  a  more  or  less  marked  degree,  and  the  collection 
of  exudates  in  body  cavities,  together  with  dysj)nea.  Tiie 
pulse  is  of  high  tension,  diminished  in  frequency,  and 
may  be  arhythmic.     The  skin  has  a  wax-like  pallor. 

Course. — Improvement  and  recovery  with  increased  ex- 
cretion of  urine  and  disaj^pea ranee  of  albuminuria  may 
gradually  set  in,  even  in  the  severest  types,  after  a  dura- 
tion of  weeks  mikI  after  repeated  relapses.  Life  may,  how- 
ever, be  tlircateiu'd  by  extensive  circulatory  interference, 
and  by  the  retention  of  the  urine  and  its  jmisonous  nieta- 


390  DISEASES  OF  THE  KIDNEYS 

bolic  products  in  the  collecting  tubules.  Such  di.sturl>- 
ances  include  dilatation  and  hyixrtrophy  of  the  left  ven- 
tricle, edema  of  the  glottis,  lungs,  and  brain,  and  also 
uremia  (coma  and  convulsions). 

Prognosis. — Inasmuch  as  cases  which  are  mild  at  the 
beginning  may  rapidly  change  to  severe  forms  of  nephritis, 
the  prognosis  must  always  be  dubious,  yet  it  is,  in  general, 
more  favorable  in  children  (excepting  infants)  than  in 
adults.  The  conversion  of  acute  into  chronic  forms  is 
fairly  rare.  Possible  complications  are  pneumonia,  pleu- 
ritis,  endo-  and  pericarditis,  and  meningitis. 

The  diagnosis  can  only  be  made  with  certainty  when  the 
urine  constantly  contains  a  marked  amount  of  albumin 
and  when  the  sediment  presents  an  abundance  of  casts; 
also  when  the  amount  of  urine  is  diminished  simulta- 
neously with  the  occurrence  o^  albumin  and  blotxl  in  the 
urine,  with  the  subsequent  development  of  dropsy.  The 
single  symptoms,  like  dropsy,  albuminuria,  and  hematuria, 
occur  also  indei)endently  of  nephritis,  as  in  heart  and 
pulmonary  disease  and  in  anomalies  of  the  blood. 

Treatment. — Rest  in  bed ;  diet  should  consist  largely 
of  milk  ;  increase  diuresis  with  lemonade  and  mineral 
water,  and  diaphoresis  by  means  of  hot  baths  and  other 
sweating  procedures.  For  the  uremia  cause  depletion  by 
way  of  the  intestines ;  ice-cap  to  the  head,  enemata  of 
chloral,  lumbar  puncture  (Seiffert),  and,  if  necessary,  vene- 
section (Baginsky)  followed  by  infusion  of  normal  salt 
solution  (Leube).  In  hemorrhagic  nephritis,  ice-cap  to 
the  renal  region.  A  cliild's  spoonful  of  the  infusion  of 
ergot  (2  :  100)  every  two  hours. 

CHRONIC  NEPHRITIS 

The  various  types  of  chronic  parenchymatous  nephritis 
have  occasionally  been  observed  even  in  children.  Its 
origin  may  sometimes  be  traced  with  a  certain  amount  of 
surety  to  a  preceding  infectious  disease,  but  in  other  cases 
the  etiology  is  not  clear  and  the  coiu'se  is  so  atypic  that  it 
is  difficult  to  classify  the  condition  under  the  known  divi- 


URINARY  CONCRETIONS  391 

sions  of  renal  diseases.  Of  the  more  characteristic  forms, 
the  interstitial  type,  contracted  kidney,  is  more  common 
than  the  parenchy  matons  form,  large  white  or  sicollen  kidney. 
In  the  former  case  the  urine  is  increased  in  amonnt,  its 
specific  gravity  is  lower  than  normal,  and  the  amount  of 
albumin  is  slight,  whereas  in  the  latter  type  of  renal  dis- 
ease the  urine  is  sparse  in  amount,  saturated  with  albumin, 
casts,  and  blood. 

Amyloid  degeneration  of  the  kidneys  is  comparatively 
rare  in  children  (lardaccous  kidney).  It  occurs  in  associ- 
ation with  amyloid  degeneration  of  the  spleen  and  liver, 
prolonged  suppuration  of  the  bones,  chronic  pulmonary 
and  glandular  tuberculosis,  and  syphilis.  The  urine  ob- 
tained by  catheterization  is  pale  and  contains  a  large 
amount  of  albumin.  Profuse  diarrhea  and  persistent 
dropsy  are  usually  ])resent. 

The  prognosis  of  the  contracted  and  of  the  white  kidney 
is  absolutely  fatal,  but  that  of  the  amyloid  kidney  de- 
pends upon  the  duration  of  the  causal  condition. 

Treatment. — A  mild  and  not  too  strict  dietetic  regime. 
Avoid  exposure  to  cold  ;  hot  douches  and  warm  baths. 
As  diuretics,  employ  caffein,  digitalis,  potassium  acetate, 
or  camphor. 

URINARY   CONCRETIONS 

Uric-acid  infarcts  in  the  newborn  are  frequent  in  the  first 
davs  of  life  and  usually  disappear  when  sufficient  fluid 
is  'ingested.  This  may  become  so  excessive  during  the 
first  days  of  life  because  of  the  small  amount  of  urine 
secreted  that  the  collection  of  uric-acid  salts  and  free  uric 
acid  in  the  straight  uriniferous  tubules  leads  to  the  for- 
mation of  uric-acid  infarcts.  The  irritation  due  to  the 
collection  of  nitrogen-containing  excrementitious  material 
causes  the  kidnev  to  become  hyperemic,  and  as  a  result 
of  the  circulatory  disturbances  albumin  is^  excreted 
(euglobulin).  Examination  of  the  urine,  which  is  de- 
creased in  amount,  shows  small  quantities  of  albumin  off 
and  on  during  the  first  tAvo  weeks  of  life,  few  hyaline 
casts  and  epithelium,  as  well  as  yellowish-red  granular 


392 


DISEASES  OF  THE  KIDNEYS 


portions  of  the  infarcts,  that  is,  uric-acid  crystals.  The 
organ  presents  the  changes  of  hyperemia  and  yellowish- 
red  striations  in  the  ))yramids. 

Nephrolithiasis. — Renal  sand,  grav^el,  or  calculus  forms 
with  esjx^cial  frequency  in  children  during  the  first  year 
of  life,  and  in  the  pelvis  as  well  as  in  the  parenchyma  of  the 


Fia.  129. — Uric-acid  infarcts  in  the  kidney  of  a  newborn  infant.  A 
freshly  isolated  uriniferous  tubule  from  the  medulla,  which  is  partially 
filled  with  spheric  and  glaiid-like  concretions.  Enlarged  280  times. 
(From  Diirck,  Atlas  of  General  Patlwluijic  Ilintology.) 


kidney.  As  etiologic  factors  we  have  over-  and  insuffi- 
cient feeding  (especially  with  food  rich  in  nitrogen),  pro- 
fuse discharge  of  body  juices,  and  marked  loss  of  tissue 
— vomiting  and  diarrhea,  atrophy  (Comby).  The  concre- 
tions consist  mainly  of  free  uric  acid  and  uric-acid  salts 
and,  more  rarely,  of  calciiun  oxalate,  cystin,  and  phos- 
phates. Renal  sand  and  gravel  usually  effect  no  mani- 
festations of  disea.se,  and  the  renal  calculi  only  after  they 


URINARi'  COyCRETIONS  393 

have  reached  a  certain  size  (lentil  to  bean  size).  Then 
they  may  call  forth  hemorrhages  and  inflammatory  proc- 
esses in  the  renal  pelvis  or  parenchyma  (pyelitis,  i)yelo- 
nephritis) ;  or,  in  case  of  difficult  passage  through  the 
ureter,  renal  colic  and  even  hydronephrosis  may  be 
caused. 

Chief  Symptoms. — Restlessness  or  pain  ujjon  micturi- 
tion. Pains  in  the  region  of  the  kidney  radiating  toward 
the  bladder.  Frequent  discharge  of  small  amounts  of 
bloody  urine  containing  an  abundance  of  sediment. 
Passage  of  concretions. 

Treatment. — A  diet  poor  in  nitrogen  ;  massage  and 
gymnastics,  carbonate  and  alkaline  waters.  For  calcium- 
oxalate  stone  give  sodium  phosphate  (2  to  10  per  cent.), 
for  pliosphatic  concretions  administer  citric  acid.  Hot 
ap|)lications  to  relieve  colic. 

Vesical  Calculi. — Vesical  calculi  are  equally  as  frequent 
as  renal  calculi,  especially  in  boys  up  to  ten  years  of  age 
(40  per  cent,  of  all  cases  of  lithiasis).  The  nucleus  of 
the  stone  is  formed,  as  a  rule,  by  uric-acid  concretions 
washed  out  of  the  kidneys ;  less  rarely  they  are  formed 
primarily  in  the  bladder  from  the  sediment  of  alkaline 
urine.  The  process  is  favored  by  mechanical  obstruc- 
tions to  the  outflow  of  the  urine,  as  in  phimosis  and 
similar  conditions.  The  color,  form,  and  size  of  the 
stones  vary  considerably ;  in  rare  cases  they  may  fill 
almost  the  whole  bladder  (the  stones  enlarge  in  the  blad- 
der by  the  deposit  in  concentrically  arranged  layers  of 
cystic  urinary  sediment). 

Sj/mpfoms. — The  disturbances  caused  by  cystolithiasis 
are  partly  mechanical  and  partly  inflammatory  in  nature: 
Displacement  of  the  neck  of  the  bladder  by  a  stone  may 
lead  to  more  or  less  severe  disturbances  of  micturition. 
The  irritation  of  the  mucous  membrane  by  the  stone  pro- 
duces vesical  catarrh  and  inflammation. 

CJiamctevktic  Plienomena. — Temporary  pains,  radiating 
toward  the  perineum  and  glans  |)enis,  are  caused  mainly 
when  the  body  is  moved  or  shaken  :  frequent  discharge 
of  feces  and  "urine  ;  frequently  sudden   stoppage  of  the 


394  DISEASES  OF  THE  KIDNEYS 

urinary  stream,  after  which  the  urine  is  passed  only  in 
drops  or,  indeed,  it  cannot  be  passed  at  all  for  hours  or 
even  days  (emptying  of  the  bladder  is  sometimes  possible 
when  the  posture  is  altered  or,  if  spasm  of  the  bladder 
exists,  in  a  hot  bath) ;  in  some  cases  in  place  of  retention 
we  observe  incontinence  of  urine.  The  condition  of 
the  urine :  Sometimes  clear,  at  other  times  turbid  and 
containing  cystic  sediment,  or  also  blood  and  fragments 
of  concretions.  Noteworthy  in  cystolithiasis  of  children 
is  the  frequent  tendency  to  jwohipsus  recti  and  the  incli- 
nation of  boys  to  manipulate  the  penis  (often  elongated) 
during  retention  of  urine  (Henoch).  Small  concretions 
may  obstruct  the  urethra,  prevent  the  passage  of  urine, 
and  produce  painful  infiltration  of  the  perineum,  scro- 
tum, and  penis. 

The  diagnosis  is  made  certain  by  examination  with  the 
sound  (metallic  sound,  clicking). 

The  prognosis  is  doubtful.  If  of  long  standing,  ma- 
rasmus results.  The  development  of  ascending  nephritis 
is  by  no  means  a  rare  event  and  the  danger  of  uremia 
may  threaten  life.  Stones  possessing  a  rough  surface 
may  occasion  deep-seated  ulceration  of  the  vesical 
mucous  membrane  and,  later,  pericystitis  and  fatal  peri- 
neal abscesses. 

Treatment. — As  in  case  of  nephrolithiasis.  Removal 
by  operation  as  soon  as  possible. 


PYELITIS 

{Pyelonephritis) 

Inflammation  of  the  mucous  membrane  of  the  jwlvis 
of  the  kidney  and  of  the  renal  pyramids  followed  by 
consecutive  inflammation  of  the  renal  tissue  is  also 
observed  in  children,  particularly  as  complications  of 
cystitis  {ascending  nephritis),  nephrolithiasis,  and  after 
scarlet  fever.  The  disease  runs  a  course  similar  to  that 
of  adults.  A  serious  sequel  is  the  development  of  renal 
abscess. 


POLLAKIURIA  AND  ENURESIS  395 

HYDRONEPHROSIS 

Renal  concretions,  anomalies  in  position  of  the  kidney, 
anomalies  in  the  formation  of  the  nreters  (abnormal 
length),  or  disease  of  neighboring  organs  may  displace  a 
nreter  and  prevent  the  flow  of  the  nrine  into  the  bladder 
on  the  affected  side.  In  consequence  the  urine  is  dammed 
back  above  the  obstruction,  the  renal  pelvis  and  the  up|>er 
portion  of  the  ureter  become  dilated,  and  marked  com- 
pression of  the  kidney  substance  results.  If  the  condi- 
tion is  not  relieved  the  renal  pelvis  may  finally  form  a 
cyst  the  size  of  an  adult's  head  (in  congenital  hydroneph- 
rosis birth  is  interfered  with),  in  which  only  remnants  of 
the  kidney,  which  has  been  atrophied  from  pressure,  can 
be  found.  When  the  hydronephrosis  is  extensive  the 
lumbar  region  on  the  affected  side  presents  an  immovable 
fluctuating  tumor  over  which  the  percussion-note  is  dull, 
and  tympanitic  if  the  colon  lies  above  it.  Dyspnea,  con- 
stipation, and  shooting  pains  in  the  legs  develop  as  the 
condition  progresses.  As  the  healthy  kidney  assumes 
the  duties  of  the  diseased  one  no  symptoms  of  general 
disturbance  set  in.  Radical  operations  are  followed  by 
permanent  recovery.  If,  however,  the  other  kidney 
becomes  diseased,  death  soon  follows  the  development  of 
edema  and  uremic  symptoms. 

DISEASES  OF  THE  BLADDER  AND  SEXUAL 
ORGANS 

POLLAKIURIA  AND  ENURESIS 

Two  varieties  of  disturbances  of  the  bladder  are  fre- 
quently observed  early  in  life  and  during  the  years  of 
puberty.  In  one,  called  pollakiurio,  the  urine  is  passed 
voluntarily,  but  frequently  abnormally.  In  the  second 
form,  called  e/iu/r-s/.s,  the  urine  is  passed  involuntarily  at 
night  and,  less  rarely,  during  the  day. 

Pollakiuria  is  generally  combined  with  nocturnal  enu- 
resis. This  disturbance  may  depend  upon  hysteria  or 
neurasthenia  (weakness  of  the  central  inhibitory  mech- 
anism)   or   it    may    be  of  reflex   origin,  as  in  phimosis, 


396    DISEASES  OF  BLADDER  AND  SEXUAL   ORGANS 

balanoposthitis,  lithiasis,  bucteriiiria,  oxyuriasis,  adenoid 
vegetations,  etc.  This  anomaly  rarely  persists  beyond 
puberty,  and  the  general  health  remains  uninfluenced, 
aside  from  the  psychic  depression  seen  in  older  children. 
Treatment. — Remove  the  cause.  Institute  general  hy- 
gienic, dietetic,  and  hydrotherapeutic  measures  (limit 
liquids,  one-half  minute  treading  of  water  in  the  evening, 
elevation  of  the  end  of  the  bed,  awaken  the  child  at  reg- 
ular intervals  during  the  night).  Tonics,  such  as  tincture 
of  nux  vomica.  In  hysteria,  temporary  effect  is  fre- 
quently obtained  through  painful  procedures,  such  as  the 
use  of  the  faradization  brush;  subcutaneous  injections; 
the  passing  of  bougies.  More  recently  it  has  been  recom- 
mended to  use  automatically  ringing  electric  bells  to  con- 
trol and  cure  enuresis  (Pfaundler,  Hutzler). 

CYSTITIS 

Catarrh  and  inflammation  of  the  vesical  mucous  mem- 
brane is  influenced  in  children  as  in  adults  by  mechanical, 
chemic,  bacterial,  and  other  forms  of  irritation,  as  by 
vesical  calculi,  certain  medicaments,  and  bacteria  whicli 
have  invaded  the  bladder.  The  entrance  of  micro-organ- 
isms into  the  bladder  may  be  an  accompaniment  to  va- 
rious inflammatory  affections  of  the  genito-urinary  ap- 
paratus or  of  its  neighboring  organs.  Bacteriuria  may, 
however,  exist  without  producin<i:  inflammatory  irritation 
of  the  bladder  or  without  constitutional  symptoms.  The 
most  frequent  form  of  cystitis — colicystitis  (Escherich) — 
in  childhood,  especially  during  the  nursing  period,  is 
usually  a  secondary  manifestation  of  vulvovaginitis  or 
inflammation  of  the  colon.  In  these  conditions  the  Ba- 
cillus coli  passes  from  the  infected  external  genitalia 
through  the  urethra  into  the  bladder,  and  perhaps  also  by 
way  of  the  blood-  and  lymph-vessels  through  the  dam- 
aged intestinal  e})ithelium  and  pelvic  connective  tissue. 
The  infected  urine  primarily  causes  only  mild  symptoms 
of  irritation  (bacteriuria),  later,  catarrhal  and  inflamma- 
tory changes  of  the  vesical  mucous  membrane  (cystitis), 
and,  finally,  the  passage  of  the  bacteria  through  the  upper 


CYSTITIS  397 

urinary  tract  causes  a  marked  purulent  inflammation  of 
the  pelvis  of  the  kidney  and,  indeed,  of  that  organ  itself 
(pyelitis,  pyelonephritis,  ascending  suppurative  nephritis). 
The  urine  in  colicystitis  is  cloudy  and  turbid,  similar  to 
a  bouillon  culture  of  bacteria ;  its  reaction  is  acid,  odor 
foul,  and  a  slight  amount  of  albumin  is  present.  It  con- 
tains a  large  number  of  colon  bacilli  and  pus-cells,  less 
commonly,  red  cells  and  desquamated  epithelium  ;  casts 
are  absent.  In  consequence  of  the  irritation  the  urine  is 
passed  frequently  and  in  small  amounts.  Locally,  the 
region  of  the  bladder  is  sensitive  on  pressure.  Tlie  re- 
maining clinical  symptoms,  fever  and  disturbance  of  the 


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%i 


'<r/.%    war  i' 


Fig.  130. — The  urine  in  colicystitis. 

genend  health,  vary  considerably  according  to  the  inten- 
sity, duration,  and  extent  of  the  process.  Pronounced 
cases  may  run  a  chronic,  intermittent  course,  which 
stretches  over  many  weeks  and  months ;  or  the  disease 
may  end  fatally,  due  to  an  asccn<ling  nephritis. 

Chief  Characteristics. — Dysuria  ;  absence  of  casts  in  the 
urine,  whioli  is  rich  in  pus  and  bacteria.  In  the  presence 
of  diphtheria  and  articular  rheumatism  vvc  should  con- 
sider the  possibility  of  a  diphtheritic  or  tuberculous 
cystitis. 

Treatment  of  Colicystitis. — Rest  in  bed  ;  a  non-irritat- 
ing diet ;  urotropin  or  salol  (0.25  to  0.5  gm  )  three  to  five 
times  a  day. 


398    DISEASES  OF  BLADDER  AND  SEXUAL   ORGANS 

PREPUTIAL  EPITHELIAL  ADHESION 

In  newborn  boys  a  partial  or  total  epithelial  adhesion 
exists  normally  between  the  inner  layer  of  the  prepuce 
and  the  glans  |>enis.  Dysuria  develops  if  the  urethral 
orifice  is  partially  covered,  and  the  retention  and  degene- 
ration of  the  smegma  (the  result  of  stagnation  of  urine) 
causes  irritation  and  inflaramatioji  accompanitnl  by  a  puru- 
lent secretion — halanoposthitia.  The  adhesions  arc  easily 
loosened  with  a  blunt  sound  ;  they  may  also  disappear 
spontaneously  within  the  first  year. 

PHIMOSIS 

Epithelial  adhesion  of  the  prepuce  is  frequently  com- 
bined with  constriction  of  its  inner  layer  (more  rarely  also 
the  outer) — phimosbi.     The  results  of  this  anomaly,  which 


Fig.  131. — Phimosis  in  a  boy  three  years  old.  Kcpo.sitioii  iiiipo.ssible 
on  account  of  marked  constriction  of  the  inner  jireixitial  layer  (hour- 
glass shape). 

is  secondary  to  inflammatory  condition.s — balanitis,  balano- 
posthitis — or  congenital  in  origin  (in  which  case  the  pre- 


PHIMOSIS 


399 


Fig.  132. — Case  of  phimosis  after  operation.     Postoperative  edema  (third 
day).     Prepuce  divided  to  the  rctroglaudular  sulcus.     No  suture. 

puce  is  usually  elongated  and  thickened),  are  to  a  certain 
extent  the  same  as  in  preputial  adhesion  and  consist  of 


Fig.  134.— Phimosis.     Attempt  to  stretch  with  dressiug-forceps. 


400    DISEASES  OF  BLADDER  AND  SEXUAL   ORGANS 

(lysuria  and  balanoposthitis.  Excessive  straining  may 
lead  to  the  development  of  hernia  and  prolapsus  ani. 
Triad  :  Phimosis,  umbilical  hernia,  hydrocele.  Increased 
tendency  to  lithiasis  and  masturbation  also  exists.  Con- 
genital phimosis  of  a  moderate  grade  usually  disappears 
spontaneously  with  the  growth  of  the  penis.  On  account 
of  the  sequelte  a  marked  constriction  requires  an  early 
operation. 

In  cases  in  which  a  ring-shaped  constriction  occurs 
when  the  foreskin  is  drawn  back,  the  outer  and  inner  j)re- 
putial  membranes  should  be  divided  on  a  grooved  director 
as  far  back  as  the  retroglandular  sulcus.  Suture  is  unnec- 
essary. Dress  with  aluminum  acetate  solution  and,  after 
a  few  days,  with  airol  paste.  Elevate  the  penis  to  lessen 
the  postoperative  edema  which  always  develops. 

In  all  other  cases  the  prepuce  may  be  drawn  buck 
without  a  bloody  operation  after  a  preliminary  loosening, 
which  is  made  especially  easy  in  a  hot  bath  or  in  narcosis 
(later  stretch  with  dressing-forceps).  Eczema  of  the  pre- 
putial border  is  a  contra-indication. 


HYPOSPADIAS.     EPISPADIAS 

Hypospadias  and  epispadias  re])resent  a  congenital  in- 
complete fissure  formation  either  on  the  ventral  or  on  the 
dorsal  surface  of  the  penis,  in  which  the  urethra  is  par- 
tially closed  or  present  in  a  rudimentary  form.  The 
penis  is  usually  very  short  and  the glans fairly  Mell  devel- 
oped. The  resulting  disturbances  of  function  may  become 
troublesome  in  later  years.     The  treatment  is  operative. 


UNDESCENDED  TESTES 

Ectopia  Testis. — If  for  any  reason  during  the  sixth  or 
seventh  fetal  month  the  beginning  of  the  descent  of  the 
testes  to  the  scrotum  is  prevented,  they  remain  either 
above  the  inguinal  ring  in  the  abdominal  cavity  or  in  the 
ring  itself  (if  one-sided,  we  have  moiwrclmiii ;  if  bilateral, 


Figs.  135,  136. — Hypospadias.  Dorsal  surface  of  penis.  Boy  one  and 
a  half  years  old.  Penis  2 cm.  [.8  in.]  long.  Glans  penis  is  disprop^trtion- 
ately  large.  The  urethra  is  an  open  groove  13  mm.  [h  in.  ]  long,  which 
extends  from  the  .scrotum  to  the  glans.  Where  this  grw>ve  approaches 
the  glans  penis  it  flattens  out.  By  means  of  a  plastic  operation  the  penis 
was  made  longer  and  the  orifice  of  the  urethra  was  formed  at  the  tip  of 
the  glans. 


Fig.  i:itJ. — Hypospadias,  ventral  surface  of  the  penis. 
26  401 


402    DISEASES  OF  BLADDER  AND  SEXUAL  ORGANS 

FIGURE  133 

Descent  of  the  Testes  (accordinf;  to  Stieda-Pansch).— a.  Position  of  the 
testis  at  about  the  fourth  fetal  mouth,  b.  Position  of  tho  testis  at  about 
the  sixth  fetal  month,  c.  Position  of  the  testis  in  the  ninth  fetal  month. 
Development  of  the  peritoneal  vaginal  process,  d.  Position  of  the  testis 
at  birth.  Development  of  the  true  tunica  vaginalis.  (From  Sultan, 
Atlas  of  Abdominal  Hernias.) 


crt/ptoi'chism),  or  they  miss  the  route  to  the  inguinal  ring 
and  pass  under  the  skin,  Poupart's  ligament,  or  peritoneum 
(ectopia  te^is).  Permanent  retention  of  the  testes  causes 
degeneration  of  these  glands. 

Treatment. — As  soon  as  the  testes  become  palpable  they 
may  gradually  be  forced  downward  by  means  of  a  hernia- 
truss-like  bandage  which  is  supplied  with  a  fork-shaped 
pad  opening  downward. 


HYDROCELE 

The  term  hydrocele  designates  a  collection  of  serous 
transudate  in  the  true  tunica  vaginalis  of  the  testes  or  in 
the  vaginal  process  which  is  not  yet  closed  (hydrocele 
communicating  with  the  abdominal  cavity).  Hydrocele 
is  either  congenital  or  acquired  and  develops  acutely  or 
in  a  chronic  manner.  In  hydrocele  of  the  testes  the  swell- 
ing, which  is  either  unilateral  or  bilateral,  lies  within  the 
scrotum  and  has  the  shape  of  an  egg  or  a  pear,  is  smooth, 
tense,  fluctuating,  transparent,  and  not  displaceable,  ex- 
cepting in  hydrocele  communicanfi.  The  testis  lies  back 
of  the  mass.  In  funicular  hydrocele  of  the  spermatic 
cord  one  or  more  oval,  round,  or  spindle-shaped  tumors 
will  be  observed  above  the  testis.  This  condition  is  dis- 
tinguished from  inguinal  hernia  by  the  position  of  the 
testis  back  of  the  mass,  by  tiie  tenseness,  transparency, 
and  percussion-note,  by  the  inability  to  displace  it,  and 
by  the  ab.sence  of  enlargement  on  coughing  and  strain- 
ing. Spontaneous  recovery  occurs  usually  in  from  three 
to  six  weeks;  otherwise  employ  iodin  preparations,  punc- 
ture and  extirpate. 


PerHen. 


Tunica 
vaginal- 
propria 


CELLULAR  ATBKSLi   OF  THE   VULVA  403 


Fig.  137. 


Fig.  139. 


Fig.  137.— The  usual  picture  of  hydrocele  of  the  testis.  "The true 
tunica  vaginalis  is  stretched  by  a  collection  of  fluid,  over  which  the  peri- 
toneum is  smoothly  drawn." 

Fig.  1.38. — Hydrocele  of  the  testis,  funicular  hydrocele  of  the  sper- 
matic cord,  and  inguinal  hernia.  "The  vaginal  process  of  the  peritoneum 
has  become  adherent  in  various  places,  on  account  of  which  several 
pouches,  one  above  the  other,  were  formed.  At  the  base  of  the  scrotum 
is  a  hydrocele  of  the  testis,  above  two  hydroceles  of  the  spermatic  cord, 
which  are  joined  to  the  hernial  sac." 

Fig.  139. — Hydrocele  communicans  and  secondary  inguinal  hernia. 
"The  vaginal  process  of  the  peritoneum  failed  to  close  on  account  of  the 
incomplete  descent  of  the  testis.  A  hydrocele  communicans  developed, 
which  also  became  tlie  hernial  sac  because  of  the  entrance  of  a  coil  of 
intestine.  This  condition  is  also  termed  A<!ntianiyrfrocp/e."  (From  Sul- 
tan, Atlas  of  Abdominal  Hernias.) 


CELLULAR  ATRESIA  OF  THE  VULVA 

Analogous  to  the  preputial  adhesion  in  boys,  we  occa- 
sionally meet  with  adhesion  of  the  labia  minora  in  girls, 
which  may  lead  to  retention  of  the  urine.  Loosen  with 
a  sound  or  knife. 


404    DISEASJCS  OF  BLADDER  AND  SEXUAL   OROAyS 

VULVOVAGINITIS.     GANGRENE   AND  PHLEGMASIA    OF 
THE  VULVA 

Inflammation  of  the  external  genitalia  in  girls  occurs 
frequently  as  a  result  of  infection  with  gonococci,  pyo- 
genic staphylococci  or  streptococci,  or  the  diphtheria 
bacillus.  It  may  also  be  due  to  non-specific  aiiections, 
uncleanliness,  the  entrance  into  the  vulva  of  oxyurides  or 
intestinal  bacteria,  the  introduction  of  foreign  bodies  for 
masturbation,  or  weakening  conditions  like  anemia  and 
chlorosis. 

The  non-specific  catarrhal  vulvovaginitis  is  generally 
accompanied  by  a  sligiit  whitisii,  mucoid  discharue  from 
the  vagina.  Tiie  local  disturbances  are  mild.  The  affec- 
tion disappears  after  the  removal  of  the  cause.  Gonor- 
rheal infection  is  usually  due  to  carelessness  of  a  mother 
or  nurse  infected  with  gonorrhea,  but  may  sometimes  fol- 
low rape,  and  in  rare  cases  it  develops  intrapartum.  The 
infectiousness  of  the  condition  is  great  and  often  leads  to 
sudden  spreading  of  the  disease  to  all  the  members  of  a 
family  or  to  all  the  inmates  of  a  hospital  ward. 

Symptoms. — The  vaginal  lips  are  red  and  swollen  and, 
like  the  entrance  to  the  vagina,  covered  with  pus.  Pres- 
sure on  the  j^erineum  causes  a  discharge  from  the  vagina 
and,  frequently,  also  from  the  urethra  of  a  thick,  yellow- 
ish-green pus  in  which  gonococci  are  more  or  less  abun- 
dant. 

Involvement  of  the  urethra  causes  dysuria.  Subject- 
ive symptoms  may  be  absent.  Recurrences  are  common. 
Gonorriieal  cystitis  is  not  an  uncommon  complication  of 
gonorrheal  urethritis. 

The  diagnosis  is  insured  by  finding  the  characteristic 
m  i  c  ro-o  rga  n  i  s  m  s. 

Treatment  of  gonorrheal  vulvovaginitis  may  be  limited  to 
rest  in  bed,  a  non-irritating  diet  (milk  and  vegetable  food), 
thorough  cleanliness  of  the  vulva,  and  sitz-baths  in  a  de- 
coction of  oak  bark.  Intravaginal  irrigation  by  means 
of  Nelaton's  catheter  with  a  lukewarm  disinfectant  solu- 
tion under  slight  pressure  is  indicated  in  many  cases.    At 


GANGRENE  AND  PHLEGMASIA    OF  THE   VULVA  405 

the  beginning  use  4  per  cent,  boric  acid,  .5  to  1  per  cent, 
protargol,  or  .2  per  cent,  itrol ;  later,  2  to  4  ikt  cent, 
aliiniinum  acetate  or  .5  per  cent,  zinol.  Beware  of  auto- 
infection  (oplitiialmoblennorrhea)  and  contact  infection  ! 
Tlie  non-specific  form  of  vulvovaginitis  after  the  cause 
has  been  removed  heals  generally  in  a  few  days  by 
means  of  cotton  tampons  soaked  in  a  solution  of  alum- 
inum acetate. 

Phlegmon  and  noma  of  the  vulva  and  vagina  which  fol- 
low infection  with  pyogenic  cocci  develop  at  times  in  very 
badly  neglected  children,  in  trauma,  and  in  infectious  dis- 
eases which  run  a  malignant  course  (scarlet  fever,  diph- 
theria, measles,  and  typhoid  fever).  The  constitutional 
or  local  symptoms,  as  in  phlegmonous  or  gangrenous  in- 
volvement of  any  mucous  membrane,  are  of  a  severe 
type.  Energetic  and  antiseptic  management  and  the  ad- 
ministration of  a  strengthening  diet  are  imperative.  (For 
Diphtheria  of  the  Vulva,  see  that  disease.) 


DISEASES  OF  THE   SKIN 

GENERAL   DISCUSSION 

Diseases  of  the  skin  are  very  common  in  children  and, 
indeed,  far  more  frequent  in  infants  than  in  older  children 
or  adults.  On  the  one  hand,  they  are  the  expression  of 
the  extraordinary  sensitiveness  of  the  infantile  skin 
toward  various — and  to  a  certain  extent — trivial  external 
injurious  influences,  and  on  the  other  hand,  the  manifes- 
tations of  an  existing  dyscrasia,  a  result  of  disease  of  the 
digestive   apparatus  or  of  the  nervous  system. 

The  treatment  must,  therefore,  not  be  purely  symptom- 
atic, and  great  stress  should  be  placed  upon  the  discovery 
of  the  causal  disease.  Furthermore,  the  tenderness  of  the 
infantile  skin  must  be  borne  in  mind  and  when  possible 
only  bland  remedies  are  to  be  employed,  which,  when 
properly  used,  will  prevent  further  injury  to  the  skin  and 
lead  to  a  cure  in  most  cases. 

NEVI 

Nevi,  or  mother^s  marks,  are  congenital  anomalies  of 
development.  We  distinguish  between  pigmentary  and 
vascular  nevi.  Pigmentary  nevi  are  referable  to  exces- 
sive deposition  of  pigment  in  the  rete  Malpighii.  Their 
color  varies  between  light  brown  and  black.  The  skin 
itself  may  remain  unchanged  and  its  surface  smooth — 
nevus  spiliis  ;  or  the  skin  may  be  wart-like  or  rough  and 
supplied  with  coarse  hairs — nevus  verrucosus ;  or  a  ]>ro- 
nounced  tumor-like  thickening  of  the  skin  exists  covered 
thickly  with  hair — nevus  pilosus.  In  rare  cases  the  pig- 
mentary nevi  involve  a  whole  region  of  the  body. 

Vascular  nevi  are  due  to  abnormal  blood-vessel  growth 
and  are  congenital  in  origin  or  acquired  at  an  early 
406 


Fig.  140. — Nevus  jnlosus.  Lai.ir<-  v'i:iyisli-l»l;ick  nevus  pilosus  which 
covers  the  body  like  a  jwir  of  swiutuiiiiK  trunks.  It  is  thickly  covered 
in  certain  areas  by  black  hairs  and  a  large  number  of  l>enign  growths 
(fibroma  nioUuscum).  There  are  also  disseminated  over  the  body  smaller 
and  larger  nevi,  which  are  nearly  all  thickly  covered  with  hair.  (Clinic 
of  von  Ranke,  Munich.) 

407 


408  DISEASES  OF  THE  SKIN 

pcricKl  of  life  (proliferation  and  new  formation  of  blood- 
vessel walls).  This  condition  occnrs  mainly  in  the  l)ap- 
illary  and  u])per  layer  of  the  skin  or  the  corinm.  The 
smooth  or  swollen  skin  presents  specks,  which  may  vary 
in  color  from  a  flaming  red  to  bluish  red — neviis  jiammeus 
or  angioma  simplex  ;  or  elevated,  swollen,  and  even  pul- 
sating growths  are  seen,  the  skin  of  which,  sometimes 
smooth  and  other  times  rough,  allows  the  dilated  vessels 
to  shine  through — angioma  cavernosum.  Nevi  increase  in 
size  during  the  early  period  of  life,  after  which  they  gen- 
erally remain  unchanged.  A  nevus  flammeus  nmy  also 
disappear  spontaneously.  When  an  angiocavernoma 
grows  to  an  excessively  large  size  it  may  become  danger- 
ous by  pressure  upon  the  surrounding  organs. 

Treatment. — Excision,  cauterization,  electrolysis,  gal- 
vanocautery,  and  radium  treatment. 

SEBORRHEA 

An  increased  activity  of  the  sebaceous  glands  exists  in 
the  newborn  child  as  in  the  fetus,  consisting  of  the  ex- 
cretion of  epidermoid  cells  which  have  undergone  fatty 
changes  and  an  active  regeneration  of  epidermis.  If  this 
function,  which  is  physiologic  in  the  newborn,  should 
continue  throughout  the  first  few  days  of  life,  and  if  the 
activity  becomes  abnormally  increased,  we  have  a  dis- 
eased condition  which  is  designated,  accoi*ding  to  whether 
it  is  spread  generally  over  the  body  or  whether  it  is 
limited  to  individual  body  areas,  as  universal  or  local 
seborrhea. 

The  commonest  situation  for  local  seborrhea  is  the 
scalp.  The  pnxlucts  of  this  process,  which  are  termed 
by  the  laity  "  scabs,"  consist  of  fat,  dust,  k)osened  ej>i- 
dermis,  and  hair  ;  these  substances  form  yellowish-brown 
or  dirty  colored,  greasy  masses,  which  are  brittle  like 
cheese  or  dry  and  possess  in  some  ciises  a  foul  odor.  This 
mass  of  material  is  spread  over  the  whole  scalp  either  in 
thin  or  thick  layers  or  it  is  found  only  in  certain  foci. 
The  scalp  beneath   this  scab  is  pale  and  moist,  as  if 


SEBORRHEA 


409 


Fig.  141.— Seborrhea  of  the  head  and  face.  Child  seventeen  months 
old.  The  scalp  and  npper  half  of  the  face  are  coated  with  an  uninter- 
rupted layer  of  thick,  dirty  sebum.    (Clinic  of  Escherich,  Vienna.) 


410 


DISEASES  OF  THE  SKIN 


a)  ~  -  a  S      J 


ICHTHYOSIS  411 

covered  with  oily  drops  of  sweat,  and  not  rarely  it  is  in- 
flamed and  eczeniatous  from  the  macerating  action  of 
altered  skin  secretion.  The  portion  of  the  scalp  covered 
by  hair  is  less  damaged  ;  the  hair  loosens  and  falls  out 
and  disk-shaped  areas  of  baldness  result. 

Universal  seborrhea  of  the  newborn  infant,  also  desig- 
nated as  cutis  sebacea  and  congenital  ichthyosis,  is  due  to  a 
constant  renewal  of  the  fornix  caseosn  (after-birth),  which 
dries  and  covers  the  whole  body  with  a  horn-like  sub- 
stance. The  stiff  coating  of  the  skin  varies  from  a 
yellowish-  to  a  brownish- red  color  and  possesses  a 
varnish-like  gloss  (according  to  Hebra  it  resembles  the 
skin  of  a  half- roasted  sucking  pig).  i'he  body  presents 
a  statue-like  immobility  on  account  of  the  tightness  and 
stiffness  of  this  coating. 

If  the  mouth  is  involved  the  act  of  nursing  is  impos- 
sible ;  yet  the  mouth,  eyes,  and  anus  usually  remain 
unaffected.  Deep  tears  in  the  covering  on  the  face  and 
at  the  joints  show  the  lamellar  structure  of  the  deposit 
of  sebum.  It  may  be  drawn  off  in  these  regions  in  large 
fragments.  The  skin  underneath  this  coating  is  slightly 
red,  shiny,  and  soon  becomes  covered  again  with  masses 
of  sebum.  The  child  soon  dies  from  inanition  and  loss 
of  body  warmth  (Kaposi,  Escherich). 

Treatment. — The  sovereign  remedy  in  the  treatment  of 
seborrhea  is  sulphur,  in  the  form  of  10  per  cent,  sulphur 
and  Lassar's  paste  or  sulphur  baths.  The  masses  of 
sebum  may  be  loosened  by  means  of  warm  oil,  c«Kl-liver 
oil,  butter,  or  boric-acid  ointment,  and  removed  with 
lukewarm  soap-water  (glycerin  soap). 

ICHTHYOSIS 

( Fish-scd/e.  Du'fease) 

Ichthyosis  is  a  skin  disease  transmitted  by  heredity, 
which  consists  of  thickening  of  the  eoriiuu,  together 
with  a  uniform  hypertrophy  of  the  jvapillary  bodies  and 
and  an  increase  of  cuticular  pigment.  The  sebaceous 
glands  are  atrophic  (contrary  to  congenital  ichthyosis). 


412  DISEASES  OF  THE^  SKIN 

PLATE    40 

Uniyersal  Seborrhea  (Cutis  Sebacea,  Congenital  Ichthyosis)  of  a 
Mild  Type.— The  body  of  a  child  eight  days  old,  covered  with  a  thin 
brovvuish-red,  shiny  layer  of  sebum,  which  has  been  torn  in  many  places 
by  the  voluntary  movements  of  the  child,  and  appears,  therefore,  to  be 
composed  of  a  large  number  of  small  and  large  scales  which  have  white 
borders.  Recovery  followed  the  usual  treatment  of  seborrhea.  (Clinic 
of  von  Winckel,  Munich.) 


Symptoms. — As  a  result  of  the  interference  with  the 
function  of  the  sebaceous  glands  the  skin  is  dry,  markedly 
scaly,  wrinkled,  and  rough  on  account  of  the  thickening 
and  prominence  of  the  normal  furrows  of  the  skin.  In 
a  more  severe  form  of  this  disease  we  note,  in  place  of 
the  furrows,  more  or  less  deep  painful  fissures  (especially 
in  the  region  of  the  elbow-joint)  ;  as  a  result  of  this  fis- 
suring,  scaly,  horn-like  plates  are  formed,  which  are  pig- 
mented a  dirty  grayish-brown  to  grayish-green  color  and 
have  pale  borders.  Severe  cases  are  accompanied  by  the 
formation  of  true  horns.  Active  shedding  of  the  horny 
mass  occurs. 

The  disease  generally  attacks  almost  the  whole  area  of 
the  body  symmetrically,  especially  the  extensor  surfaces 
of  the  extremities  ;  the  face,  genitalia,  palms,  and  soles, 
however,  remain  uninvolved.  On  the  other  hand,  in 
exceptional  cases  the  arms  and  soles  are  alone  affected — 
iehthyosis  palmaris  et  plantaris.  Almost  as  rare  is 
ichthyosis  foUicularis,  in  which  the  horny  formation  in- 
volves only  the  skin-follicles  (Lesser).  Ichthyosis  gen- 
erally begins  in  the  course  of  the  first  or  second  year 
of  life  and  continues  practically  unchanged  throughout 
life.     The  general  health  is  only  slightly  disturbed. 

Diagnosis. — Trophoneuroses  may  occasionally  simulate 
ichthyosis,  yet  they  are  limited  to  narrow  confines  and  do 
not  arise  symmetrically.  Lichen  pilaris  may  be  mistaken 
for  ichthyosis  foUicularis,  yet  is  rarely  met  before  pu- 
berty. 

Prognosis, — Absolute  cure  is  rare. 

Treatment. — Warm  soap-baths,  followed  by  rubbing  in 
of  fat,  soft-soap,  or  5  to  10  per  cent,  sulphur  ointment. 


^^r 


) 


ICHTHYOSIS 


413 


Fig.  1-13.— Ichthyosis.     (See  text.) 


414  DISEASES  OF  THE  SKIN 

PLATE  41 

Pemphigus  Neonatorum.— Child  four  weeks  old.  Vesicles  appeared 
in  the  skin  cue  day  after  birth.  Parents  and  midwife  healthy.  Child 
emaciated,  anemic,  and  weak.  The  vesicles  are  covered  with  a  sallow 
skin  all  over  the  body.  They  are  most  abundant  on  the  flexor  sides  of 
the  lower  extremities.  Their  color  is  whitish  or  grayish  yellow  and  they 
vary  in  size  from  that  of  a  lentil  to  a  silver  dollar.  (The  palms  of  the 
hands,  as  well  as  the  soles  of  the  feet,  are  free,  excepting  one  large  ves- 
icle on  the  left  great  toe.)  The  smaller  vesicles  are  tense,  whereas  the 
larger  ones  are  relaxed  and  their  membranes  wrinkled  or  toru  and  col- 
lapsed. The  contents  of  the  vesicles  consist  of  a  serum  which  is  clear  or 
turbid  with  pus  (the  bacterial  findings  showed  the  presence  of  the  Staph- 
ylococcus pyogenes  aureus).  In  many  areas  nothing  but  scabs  remained 
or,  where  these  have  been  removed,  specks  are  noted  which  are  red  and 
weeping  or  covered  with  a  delicate  membrane  surrounded  by  a  white 
epidermic  ring.  High  septic  fever.  Death  in  four  days  after  admission. 
(Cliuic  of  von  Banke,  Munich.) 

PLATE  42 

PempUgus  Syphiliticus  (Exanthema  papulo-vesico-pustulosum).— 
"  Infant  six  days  old.  Papular  and  vesicular  eruption  to  the  size  of  a  pea 
on  the  legs  and  soles  of  the  feet  which  contained  pus  and  surrounded  by 
an  inflammatory  areola.  On  the  following  day  the  extensor  surface  of 
the  lower  extremities,  nates,  and  back  also  became  covered  with  a  pro- 
fuse papular  eruption.  A  vesicular  and  papular  eruption  occurred  be- 
tween the  papules.  The  nose  remained  uninvolved.  Death  on  the 
seventeenth  day  from  bronchopneumonia  and  gastro-intestinal  catarrh. 
At  necropsy,  among  other  changes,  infiltration  of  the  liverand  spleen  was 
found  to  be  present."  (From  MraZek,  Atlas  of  Si/phiUx.)  Primary  de- 
velopment of  copper-colored  papules  and  the  secondary  conversion  of 
these  into  pustules.  In  pemphigus  neonatorum,  on  the  contrary,  we 
note  primarily  the  formation  of  vesicles. 


PEMPHIGUS  NEONATORUM 

Pemphigus  neonatorum  is  a  contagious  skin  di.sease 
which  generally  runs  a  favorable  courseandis  accompanied 
by  the  formation  of  vesicles  ;  it  develops  sporadically  and 
sometimes  also  endemically  and  epidemically.  Tlie  vesi- 
cles are  due  to  the  exudation  of  a  serous  fluid  into  the 
rete  which  causes  the  production  of  vesicles.  The  eti- 
ology of  the  disease  is  unknown. 

Symptoms. — A  number  of  lentil-  to  pea-sized  hemi- 
spheric vesicles  develop  in  various  parts  of  the  body  dur- 
ing the  middle  or  at  the  end  of  the  first  week  in  ciiildren 
enjoying  good  health ;  occasionally  their  appearance  may  be 
accompanied  by  a  slight  rise  of  temperature.   The  vesicles 


luhAt, 


TabA2. 


DERMATITIS  EXFOLIATIVA  415 

are  transparent,  grayish  red,  or  yellowish,  surrounded 
by  a  narrow  red  areola,  fairly  tightly  distended  by  serum, 
and  easily  ruptured.  With  the  ai)pearance  of  reiM}ate(l 
crops  we  may  finally  note  thirty  to  fifty  vesicles  of  vary- 
ing size  and  stage  of  development.  Large  vesicles  (as 
large  as  a  twenty-five-cent  piece)  become  flatter  and  more 
relaxed  and  are  the  last  to  rupture,  after  which  the  con- 
tents dry  up.  After  the  shell  of  the  vesicle  peels  off  the 
skin  is  seen  to  be  slightly  red,  still  moist,  but  already 
covered  with  a  delicate  tissue  and  surrounded  by  a  white 
ring  of  epidermis.  The  disease  runs  a  favorable  and 
afebrile  course  which  terminates  in  two  weeks,  provided 
no  septic  complications  set  in. 

The  malignant  form  occasionally  observed  is  accom- 
panied by  the  formation  of  huge  vesicles  on  previously 
reddened  skin,  runs  a  high  febrile  course,  and  usually 
ends  fatally  (Baginsky,  Block).  (For  Differential  Diag- 
nosis from  Syphilitic  Pemphigus,  see  that  disease.) 

Treatment. — Avoid  mechanical  injuries ;  prevent  bac- 
terial infection  ;  favor  desiccation  of  the  vesicular  con- 
tents with  dusting-powders  ;  when  extensive  exposure  of 
the  corium  occurs  resort  to  baths  of  oak  bark  decoction 
(1  pound  boiled  in  3  quarts  of  water  for  a  bath). 

DERMATITIS   EXFOLIATIVA 

An  increase  of  the  ])hysiologic  exfidiation  of  the  skin 
and  a  diffuse  serous  infiltration  of  the  rete  Malpighii  de- 
velops, occasionally  without  a  known  cause,  in  prema- 
turelv  born  an<l  unhealthy  children  during  the  first  few 
days  "of  life.  This  leads  *to  relaxation  and  loosening  of 
the  skin  to  an  extreme  degree,  and  in  certain  areas  to  a 
smooth  vesicular  elevation  of  the  same  (similar  to  large 
relaxed  pem})higus  vesicles). 

Symptoms. — The  skin  at  first  shows  a  rosy  tint  all  over, 
after  which  it  is  sjieckled  with  an  erythema-like  red  color. 
The  hornv  laver  of  the  skin  gradually  swells  and  appears 
finallv  as 'if  macerated.  In  this  stage  the  ])ressure  <»f  a 
finger  is  sufficient  to  displace  the  superficial  layer  of  the 


416 


DISEASES  OF  THE  SKTN 


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SCLEREMA  NEONATORUM  417 

skin  upon  its  base,  and  on  account  of  its  cohesive  proper- 
ties it  may  be  drawn  off  in  large  fragments.  Beneath  it 
is  seen  the  red  weeping  corium.  Such  a  displacement 
and  tearing  of  the  epidermis  occurs  with  every  move- 
ment of  the  })atient,  and  hence  we  often  see  large  sections 
of  the  superficial  skin  loosened  and  hanging  down  in 
large  shreds  or  rolled  up  like  a  knot.  Vesicular  separa- 
tion of  the  skin  is  usually  seen  only  in  dependent  re- 
gions and  on  the  extremities,  and  not  rarely  to  such  an 
extent  that  the  superficial  layer  of  the  skin  represents  a 
glove-like  coating  of  the  affected  part,  which  may  often 
be  drawn  off  in  toto  (Escherich).  The  disease  itself  is 
not  accompanied  by  fever  or  other  marked  disturbances 
of  general  health.  The  majority  of  the  patients,  how- 
ever, die  from  general  sepsis.  It  may  be  possible  to  save 
a  life  now  and  then  when  the  epidermolysis  is  not  too  ex- 
tensive and  when  the  outward  conditions  of  life  are  favor- 
able.    The  specific  treatment  is  that  of  acute  jMimphigus. 

SCLEREMA  NEONATORUM 

Sclerema  neonatorum  is  a  disease  characterized  by  hard- 
ening of  the  skin  and  loss  of  body  tem|x;rature,  which 
may  develop  in  the  form  of  sclerema  edematosum,  scle- 
rema adiposum,  or  a  combination  of  both  forms. 

Sclerema  edematosum  is  a  result  of  weakened  cardiac 
action  and  disturbance  of  heat  production  in  sickly,  ])re- 
maturely  born  infants  who  are  suffering  from  myocarditis, 
nephritis,  or  syphilis,  and  who  are  victims  of  unfavorable 
and  unhygienic  circimistances  of  life.  Slow  ca])illary  cir- 
culation and  abnormal  permeability  of  the  bloo<l- vessel 
walls  lead  to  edema  of  the  subcutaneous  tissue  and,  later, 
to  dense  infiltration  of  the  skin  and  hardening  of  the 
pauniculus  adiposus. 

Symptoms. — The  disease  begins  generally  in  the  lower 
extremities,  with  coldness,  edema,  and  hardening  of  the 
calves  and  legs.  It  then  spreads  to  the  trunk  and  in  the 
course  of  a  few  hours  or  days  it  becomes  universal.  The 
skin  of  the  affected  parts  is  tense,  shiny,  white,  mottled, 
or  reddish.     At   the  commencement  of  the  disease  it  is 


418  DISEASES  OF  THE  SKIN 

still  movable  upon  its  base,  can  be  lifted  up  in  thick  stiff 
folds,  and  pits  on  pressure.  At  a  later  stage  the  edema 
disappears  from  the  primary  foci,  the  skin  becomes  dry, 
stiff,  immovable,  and  turns  a  dirty  yellow  or  brownish 
color.  The  stiffening  of  the  skin  interferes  with  the  body 
movements  and  with  nursing  and  gives  the  face  a  peculiar 
senile  appearance.  The  whole  body  feels  cold  and  lies 
stiff,  as  if  frozen. 

Sclerema  adiposmu,  or  fat  sclerema,  is  a  result  of  exces- 
sive loss  of  water  and  serum  after  exhausting  diseases, 
especially  cholera  infantum.  The  consequent  disturb- 
ances of  circulation  and  lowering  of  the  body  temperature 
may,  in  conjunction  with  improper  feeding  and  insuffi- 
cient application  of  external  heat  during  the  first  week 
of  life,  lead  to  a  finely  granular  coagulation  and  stiffen- 
ing of  the  subcutaneous  adipose  tissue  (Knopfelraacher, 
Siegert). 

iSi/mptoms. — The  disease  spreads  rapidly,  but  spares,  as 
a  rule,  the  anterior  surface  of  the  neck  and  trunk.  The 
skin  is  dry,  without  gloss,  and  dirty  yellow  in  color ;  it 
does  not  pit  on  pressure  nor  is  it  movable  on  its  base. 
The  whole  body  is  stiffened  and  immobile  like  a  corpse. 
Both  affections,  the  sclerema  edematosum  and  the  scle- 
rema adijwsum,  possess  in  common  the  constant  and 
progressive  falling  of  the  body  temperature  about  2°  to 
3°  C.  ri.8°-3.6°  F.]  daily,  until  29°  or  25°  C.  [84.2°  or 
77°  F.j  is  reached  ;  also  a  rapid  lessening  of  all  other 
vital  functions,  which  leads,  as  a  rule,  to  death  in  a  few 
days  or,  at  the  latest,  in  two  or  three  weeks. 

Prophylaxis  and  Treatment. — Children  in  danger  of 
sclerema  should  be  provided  with  fhe  best  possible  cir- 
cumstances of  life  and,  above  all,  the  loss  of  energy 
through  dissipation  of  heat  must  be  prevented  (wrap  in 
flannels,  cotton,  hot-water  bottles,  or  incubator).  In  ex- 
ceptional cases  it  is  possible  to  save  children  suffering 
from  sclerema  by  the  application  of  hot  moist  packs,  hot 
baths  (30°  to  32°  R.  [86°-89.6°  F.]),  as  well  as  by  in- 
creasing the  capillary  circulation  by  massage,  the  cardiac 
activity  by  stimulants. 


ECZEMA  419 


ECZEMA 


Eczema  is  the  commonest  skin  disease  of  childhood. 
It  is  characterized  by  an  itching  polymoq)hous  eruption, 
and  anatomically  by  an  exudative  dermatitis  which  is 
chiefly  confined  to  the  upjiermost  layers  of  the  skin. 
This  dermatitis  consists  of  a  pronounced  serous  exudation 
and  cellular  infiltration.  The  etiologic  factor  may  be  any 
skin  irritant  of  a  chemic,  mechanical,  thermic,  or  para- 
sitic nature.  In  many  cases  this  irritation  of  the  skin  is 
only  the  exciting  cause,  the  real  factor  being  a  dyscrasic 
constitutional  anomaly  or  a  disturbance  of  metabolism, 
as  in  scrofula,  rachitis,  status  lymphaticus,  obesity,  pro- 
longed disturbance  of  digestion,  and  especially  as  a  con- 
sequence of  overfeeding. 

Symptoms. — Depending  u|K)n  the  nature  and  duration  of 
the  injurious  influence  and  upon  the  individual  predisposi- 
tion, eczema  manifests  itself  in  the  form  of  a  diffuse  red- 
dening and  |)ainful  edematous  swelling  of  the  skin,  or  in 
the  form  of  pale  or  red  itching  nodules  which  become 
rapidly  converted  into  vesicles  or  pustules  (Eczana  ery- 
tliematosum,  papufosum,  vesicuhsuniy  pu-^fnlosum).  These 
manifestations  may  undergo  resolution  in  a  few  days  or 
rupture,  and  scratching  of  the  vesicles  and  pustules  causes 
the  development  of  weeping  eczema  {Eczema  viadidans\ 
which  heals  with  the  formation  of  crusts  and  scabs,  but 
not  until  several  weeks  have  elapsed  [Eczema  crustosum, 
sqiMmosum).  Healing  may,  however,  be  considerably 
delayed  by  the  continuation  of  exudation,  which  causes 
stasis  of  the  pus-altered  serum  underneath  the  crusts 
{Eczema  impefiginosum)  or  even  purulent  destruction  of 
the  tissue  {ecthipna). 

Eczema  may  also  occur  diffusely  and  spread  over  the 
entire  body  or  remain  confined  to  certain  areas  of  pretli- 
lection  (scalp,  mouth,  lobule  of  the  ear,  cheeks,  around 
the  eyes,  nates,  genitalia,  and  the  inner  surfaces  of  the 
arms). 

A  cyclic  eczema  is  occasionally  met  with  in  which  the 
described  alterations  occur  in  regular  order  over  a  course 


420  DISEASES  OE  THE  SKIN 

PLATE  43 

Chronic  General  Eczema.— Child  a  year  and  a  half  old,  who  suffered 
since  the  first  year  of  life  from  a  skin  eruption  which  began  in  the  face  and 
then  spread  over  the  whole  body.  Otherwise  healthy  and  well  nour- 
ished. The  skin,  especially  of  the  back,  is  reddened  and  covered  with 
numerous  irregularly  grouped  yellowish-red  to  dark  red  small  nodules  of 
about  the  size  of  a  pin's  head,  also  honey-colored  or  brownish  crusts  and 
whitish  scales.    In  certain  areas  the  skin  is  markedly  infiltrated. 


of  from  three  to  four  weeks.  More  frequently,  however, 
the  disease  spreads  at  the  perii)hery  and  heals  centrally, 
or  through  irregular  recrudescences  tlie  disease  appears 
in  different  parts  of  the  body,  presenting  at  one  time 
this,  and  at  another  time  that,  pathologic  change,  and 
running  a  chronic  course  spread  over  several  months. 

In  acute  localized  eczema  the  general  health  is  but 
slightly  influenced,  excepting  perhaps  the  effects  of  pro- 
longed itching.  In  general  eczema  and  in  case  of  delayed 
healing  the  bodily  nutrition  suffers  from  fever,  sleepless- 
ness, lack  of  appetite,  and  loss  of  .serum.  Coni])lications 
to  be  considered  are  lymphadenitis,  furunculosis,  phleg- 
mon, and  gangrene. 

Course  and  Prognosis. — If  the  dermatitis  remains  su])er- 
ficial,  as  is  the  rule,  recovery  is  com])lete  and  without 
destruction  of  tissue;  otherwise  superficial  scars  remain 
(always  in  ecthyma).  If  the  disease  lasts  for  years,  the 
disturbance  in  the  nutrition  of  the  skiu  loads  to  the  for- 
mation of  permanent  tissue  changes,  including  pigmenta- 
tion, thickening  of  the  skin  with  degeneration  of  the 
hair-follicles,  sweat,  and  sebaceous  glands. 

The  prognosis  depends  upon  the  cause.  If  the  derma- 
titis proceeds  to  gangrene  and  phlegmon,  collapse  and 
death  may  follow  the  development  of  eclam])sia.  Sudden 
death  has  been  observed,  even  in  the  ab.sence  of  these 
changes,  in  children  who  are  encumbered  with  lymphatic 
constitutional  anomalies — eczema  death  (Feer). 

Chief  Characteristics  of  Eczema. — The  redness  of  the 
skin  in  eczema  di.sappears  on  pressure  ;  eczematous  pap- 
ules and  vesicles  are  usually  crowded  closely  together  in 
an  irregular  arrangement  and  are  never  of  long  duration. 


TnbA^ 


ECZEMA  421 

Removal  of  the  eczematous  crust  exposes  the  red  moist 
skin,  yet  no  loss  of  substance  from  ulceration  (excepting 
ecthyma).  In  eczema  of  long  duration  we  note,  occur- 
ring simultaneously  side  by  side,  the  various  eczematous 
types,  with  apparent  infiltration  of  the  affected  ])ortions 
of  the  skin.  The  forms  of  eczema  noted  as  especially 
frequent  in  cliildren  are  : 

Eczema  Sudamen  or  Miliaria. — This  is  a  papular  form 
of  eczema  whicli  is  caused  by  the  sweat,  and  consists  of 
closely  crowded  red  papules  of  about  the  size  of  millet 
seeds.  On  the  tip  of  the  papules  are  found  minute  vesi- 
cles which  are  clear  as  water  or  whitish  on  account  of  the 
turbidity  of  their  contents.  This  type  passes  not  infre- 
quently into  the  weeping  form  of  eczema. 

Eczema  Intertrigo. — This  is  an  erythematous  form  of 
eczema  of  skin  folds  which  have  become  macerated  by 
rubbing  against  each  other,  as  on  the  genitals,  the  nates, 
and  on  the  folds  of  the  thighs,  axilla,  and  neck.  It  is 
frequently  complicated  by  a  papular  eczema.  When  of 
long  duration  a  loss  of  epidermis  results  and  the 
weeping  type  of  eczema  develops.  When  neglected,  gan- 
grene arises. 

Crusta  Lactea  or  Porrigo  Larvalis. — This  is  a  chronic 
impetiginous  facial  eczema  which  is  especially  pecidiar  to 
the  nursing  period.  It  develops  generally  in  overfed 
infants  and  frequently  even  as  early  as  a  few  weeks  after 
birth,  and  predominates  as  an  impetiginous  crusted  and 
squamous  eczema  in  the  forehead,  cheeks,  and  ears.  It 
persists  for  many  weeks  and  even  months. 

Impetigo  Contagiosa. — This  is  an  acute  pustular  eczema 
caused  by  micro-organisms  and  transmitted  by  contact. 
It  is  distiugni.-hed  from  the  non-contagious  impetigin- 
ous eczema  by  the  size  of  the  ptistules  (as  large  or  hirger 
than  lentil  seeds).  It  is  generally  confined  to  the  face, 
yet  isolated  impetiginous  vesick\s  are  occasionally  met 
with  scattered  over  the  whole  body  (auto-infection  with 
the  fingers).  The  disease  begins  with  the  deveh)pment 
of  disseminated  red  papules  whicii  are  rapidly  converted 
into  vesicles  and  superficial  pustules.     The  latter  remain 


422  DISEASES  OF  THE  SKIN 

PLATE  44 

Crusta  Lactea. — Overfed  infant  eight  months  old.  The  eruption, 
whicli  causes  much  itcliing,  has  existed  for  three  months.  The  scalp  is 
covered  with  grayish-green  masses  of  sebum.  Where  the  latter  has  been 
scratched  off  we  may  observe  tlie  darkly  reddened  skin  covered  with 
hair,  which  is  bloody  in  some  areas  and  covered  in  other  jilaces  witli 
brownish-red  crusts  and  fat-droi)s.  The  forehead,  the  neighboring  por- 
ticms  of  the  cheeks,  and  the  areas  around  the  mouth  are  covered  with 
partly  fresh  and  incrusted  multiple  confluent  pustules.  The  skiu  of  the 
whole  face  is  markedly  red  and  rough  like  plush. 

PLATE  45 

Impetigo  Contagiosa. — The  eruption,  from  which  also  a  brother  and 
two  playmates  suffered,  Ls  claimed  to  have  existed  for  two  weeks.  Pre- 
vious to  this  time  only  the  skin  of  the  face  was  involved.  That  region 
presented  several  dozen  single  or  irregularly  grouped  pustules,  some  of 
which  are  small  (about  lentil-seed  size),  tense,  and  resting  on  a  red  and 
somewhat  infiltrated  base ;  whereas  others  are  larger,  flat,  relaxed,  and, 
to  a  large  extent,  confluent.  A  continuous  deposit  appears  on  the  upper 
lip  and  chin;  this  is  covered  by  a  honej'-yellow  to  grayish-green, 
tough,  elastic  sc^ab,  underneath  which  is  pus,  removal  of  which  exposes 
the  red  moist  corium. 

circular  in  outline  and  isolated  at  the  beginnings,  but  later 
they  coalesce  and  form,  upon  the  eruption  of  new  crops, 
irregular  figures.  The  gumma-like  crusts  which  form  are 
of  a  dirty  yellowish-green  or  brownish-red  color  if  blood 
be  present,  and  fluctuate  on  account  of  the  pus  which  has 
collected  beneath  them.  Very  similar  to  impetigo  con- 
tagiosa is  the  eczema  facialis  impetiginosum,  which  is 
usually  due  to  pediculosis. 

Ecthsrma. — This  is  a  pustular  eczema  in  which  the  in- 
flammation also  attacks  the  uppermost  layers  of  the  corium 
and  proceeds  to  ulceration  of  the  tissue.  It  is  aj>j)arcntly 
only  a  secondary  manifestation  of  scratching  and  follows 
the  same  ciiuse  in  scabies  and  prurigo.  As  a  rule  ecthyma 
consists  of  isolated  pustules,  about  the  size  of  a  pea  and 
surrounded  by  a  red  areola,  on  the  extensor  surfaces  of 
the  lower  extremities,  on  the  buttocks,  on  the  back  of  the 
hands  and  feet,  and,  rarely,  on  the  face  and  other  portions 
of  the  skin.     Healing  is  accompanied  by  scar-formation. 

Ecthyma  cachecticorum,  which  occurs  in  anemic  and 
atrophied  children  and  in  those  weakened  from  disease 
under  the  manifestations  of  sepsis,  may  run  a  fatal  course. 


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423 


Treatment  of  Eczema. — Remove  the  cause  (in  every  ease 
alter  the  diet;  provide  a  vegetable  dietary;  avoid 'over- 
feeding) and  regulate  the  intestinal  functions.     Keep  the 


Fig.  145. — Arm  bandages  of  Eversbusch.  Sleeves  reaching  from  the 
middle  of  the  arm  to  the  wrist,  which  are  composed  of  two  layers  of 
drilling,  between  wiiich  two  or  three  small  wooden  splints  are  sewed. 
The  sleeves  are  so  apjdied  that  the  splints  lie  upon  the  Hexor  siirfaco. 
They  are  fastened  by  lacing  on  the  extensor  surface.  The.se  arm  bandages 
permit  free  movement  of  the  hand.s,  but  prevent  flexing  of  the  arms  and 
hence  scratching  of  the  face.  They  are  also  recommended  in  ciiiidren 
who  have  undergone  intubation,  in  order  to  prevent  the  removal  of  the 
tube  by  the  thread  to  which  it  is  fastened. 

skin  thoroughly  cleaned  and  avoid  fresh  injury.     Attempt 
to  assist  and  hasten  the  natural  healing  process  with  as 


424  DISEASES  OF  THE  SKIN 

bland  remedies  as  possible.  Avoid  rubbing,  pressure,  or 
wetting  of  tlie  eczematous  areas.  Hence  proiiibit  the 
wearing  of  too  tight  or  too  warm  clothing  or  such  as  will 
irritate  the  skin  (wool).  Remove  as  rapidly  and  as  care- 
fully as  possible  from  the  diseased  jx)rti()ns  of  the  skin 
urine,  feces,  sputum,  and  vomitus  by  means  of  gentle 
swabbing  with  cotton  (dry  or  soaked  in  sweet  oil).  Limit 
bathing  and  washing  to  the  uninvolved  portions  of  the 
body.  If,  however,  occasional  cleaning  is  necessar}', 
employ  cotton  (do  not  use  a  sponge,  which  is  cleaned  with 
difficulty)  and  only  boiled  water  to  which  has  been  added 
a  little  aluminum  acetate  or  a  1  per  cent,  solution  of  boro- 
glycerin;  dry  by  gentle  swabbing  and  not  by  rubbing. 
Add  to  the  baths  wheat-bran  or  potassium  permanganate 
solution  until  a  rose-red  color  is  obtained. 

The  arm  bandage  of  Eversbusch  is  employed  to  pre- 
vent injurious  scratching  and  the  diseased  areas  of  the 
skin  are  protected  by  an  ointment  dressing  or  by  zinc 
oxid  adhesive  plaster.  The  itching  is  lessened  by  wash- 
ing with  alcohol  or  by  the  addition  of  menthol,  carbolic 
acid,  etc.,  and  the  use  of  dusting-powders,  ointments,  or 
pastes.  To  secure  healing"  in  children  it  is  sufficient,  as 
a  rule,  to  remove  the  causal  condition  and  avoid  injurious 
factors. 

The  following  dermatotherapeutic  measures  are  recom- 
mended :  In  case  of  eczema  caused  by  the  sweat,  miliaria, 
and  intertrigo  use  bland  dusting-powders  (zinc  oxid,  5.0 
gm. ;  talcum  venet.,  30.0  gm.,  with  or  without  J  to  1  per 
cent,  menthol);  macerated  areas  are  first  painted  with  a 
2  to  3  per  cent,  solution  of  silver  nitrate.  In  other  acute 
forms  of  inflammatory  eczema  (papular,  vesicular,  pustu- 
lar) make  cold  moist  applications  with  aluminum  acetate 
(15:500).  In  the  crusty  impetiginous  type  of  eczema 
resort  to  mechanical  removal  of  the  scabs  after  they  have 
been  previously  softened  with  aluminum  acetate  applica- 
tions, ointments,  or  oil  dressings  ;  afterward  apply  alumi- 
num acetate  until  the  inflammation  has  undergone  reso- 
lution and,  finally,  use  a  drying  paste  (Lassar's  j>aste). 
In  isolated  impetigo  contagiosa  remove  the  scabs,  paint 


PRURIGO  426 

with  silver  nitrate  solution,  and  apply  a  paste.  Ecthyma 
should  be  first  treated  with  corrosive  sublimate  dressings 
and  later  with  applications  of  aluminum  acetate.  Of 
value  in  squamous  and  chronic  eczema  is  an  ointment 
of  sulphur  or  1  part  of  liquor  carbonis  detergens  with  9 
parts  of  zinc  paste.  Occasionally  very  efficient  results 
are  obtained  by  altering  the  diet,  and  especially  in  the 
administration  of  buttermilk. 


PRURIGO 

Prurigo  is  a  chronic  inflammatory  affection  of  the  skin 
which  begins  with  an  obstinate  urticaria  and  a  character- 
istic papular  eruption  at  about  the  eighth  to  the  twelfth 
month  of  life.  The  disease  is  accompanied  by  marked 
itching  and  persists,  as  a  rule,  throughout  life.  The  anat- 
omic findings  are  similar  to  the  papular  and  chronic  forms 
of  eczema. 

Symptoms. — The  minute  papules,  which  do  not  develop 
generally  until  the  second  year  of  life,  are  pale  or  red,  of 
a  dense  consistency,  and  occasion  excessive  itching.  They 
appear  chronically  in  the  form  of  repeated  eruptions  and 
predominate  on  the  extensor  surface  of  the  extremities,  on 
the  nates,  in  the  sacral  region,  and  at  times  in  other  local- 
ities, but  they  never  appear  on  the  flexor  surfaces.  The 
papules  are  generally  scratched  and  covered  with  small 
bloody  scabs,  which  remain  in  place  even  after  the  disap- 
pearance of  the  papules.  Continued  eczema  causes  streaky 
excoriations  and  the  secondary  development  of  all  the 
different  varieties  of  eczema.  Finally,  the  skin,  especially 
on  the  legs,  which  are  always  most  severely  attacke<l,  pre- 
sents brownish  pigmentation,  infiltration,  thickening,  and 
dryness.  The  lymj)h-nodes,  especially  the  crunil,  under- 
go indolent  swelling  and  feel  like  flat  pebbles.  The 
sleeplessness  and  the  loss  of  body  fluids  cause  a  rapid  de- 
cline in  health  and  the  child  looks  pale  and  haggard. 

Chief  Characteristics. — The  skin  of  the  extensor  surfaces 
of  the  extremities  is  covered  with  minute  papules  and 
scabs,  and  later  with  secondary  eczema.     The  integument 


426  DISEASES  OF  THE  SKIN 

PLATE  46 

Erjrthema  Exudativiun  Multiforme.— Girl  fourteen  years  old.  Little 
rouud  decidedly  red  papules  developed  without  a  demonstrable  cause 
upou  the  backs  of  both  hands.  They  enlarged  rapidly  and  upon  spread- 
ing to  the  fingers  occasioned  itching  and  pain.  The  general  health  was 
otherwise  undisturbed.  The  eruption,  which  covered  nearly  the  whole 
back  of  the  hands,  coalesced  into  areas  varying  between  a  five-cent  piece 
and  a  silver  dollar;  their  wall-like  elevated  edges,  which  were  joined 
by  curved  lines,  were  dark  red  in  color,  whereas  their  centers  were  some- 
what pale,  bluish  red,  and  presented  in  several  areas  brick-rod  spots 
(fresh  papules  beginning  at  the  center — erythema  iris).  Repeated  occur- 
rence of  fresh  crops.  Eecovery  in  five  weeks.  (Clinic  of  Escherich, 
Vienna.) 


is  scratched,  pigmented,  and  infiltrated.  The  flexor  sur- 
faces of  the  joints  are  always  uninvolved.  Glandular 
swelling.  Continual  itching.  A  chronic  course  marked 
by  recurrences. 

Prognosis. — A  temporary  improvement  is  all  that  may 
be  hoped  for.  Recovery  from  the  severe  tyj>es  is  impos- 
sible. 

Treatment. — Anoint  with  1  to  3  per  cent,  naphtol 
ointment  three  times  a  week  in  the  evening.  Wash  in 
bath  with  naphtol  and  sulphur  soap.  Cod-liver  oil, 
regulation  of  the  diet,  and  sojourn  in  the  country. 

ERYTHEMA   EXUDATIVUM    MULTIFORME  AND 
ERYTHEMA   NODOSUM 

Erythema  exudativum  multiforme  and  erythema  notlo- 
sum  are  inflammatory  dermatoses  which  follow  irritation 
of  the  vasmotor  centers.  The  etiology  is  still  uncertain ; 
they  are  influenced  to  a  certain  extent  by  diseases  of  the 
internal  organs  (auto-intoxication).  Characteristic  of  the 
angioneurotic  erythema  is  the  development  of  red  sjiecks, 
whose  periphery  is  dark  red  and  whose  center  is  colored 
a  bluish  red.  The  dark  red  color  is  duo  to  active  conges- 
tion with  blood,  and  the  central  blue  coloration  is  caused 
by  consecutive  relaxation  hyperemia  (stimulation  and 
paralysis  of  the  vasoconstrictors).  The  relaxation  of  the 
blood-vessel  walls  may  also  lead  to  the  escape  of  hemo- 
globin, serum,  and  even  red  blood-cells,  which  cause  dis- 


Tab 


f).^ 


ERYTHEMA  EXUDATIVUM  MULTIFORME        427 

coloration  and  the  formation  of  jxipules,  nodules,  vesicles, 
and  hemorrhages  (Kaposi). 

Erythema  Exudativiun  Multiforme. — This  disease  con- 
sists of  simultaneous  and  symmetric  development  of  dis- 
seminated, flat,  or  somewhat  elevated  red  sj)ecks  about  the 
size  of  a  pin's  head  on  the  backs  of  both  hands  and  feet, 
as  well  as  on  neighboring  |X)rtions  of  the  forearms  and 
legs.  These  spots  rapidly  enlarge  to  the  size  of  a  silver 
dollar  and  tend  in  many  instances  to  coalesce.  The 
centers  of  the  larger  specks  appear  bluish  red,  and  when 
hemoglobin  escapes  from  the  vessels  they  present  various 
colors,  from  blue  to  yellow,  green,  and  brown.  If  fresh 
primary  specks  appear  in  the  same  areas  they  assume,  on 
account  of  the  hematin  already  present,  a  brick-red  color 
(erythema  iris).  According  to  the  grade  of  exudation 
we  note  the  formation  of  papules,  nodules,  vesicles  (ery- 
thema papulatum,  urticarium,  vcsiculosum,  bullosum ; 
with  a  peripheral  vesical  border:  herpes  circinatus,  herpes 
iris).  The  affection  may,  in  the  course  of  time,  attack 
the  skin  of  the  wiiole  body,  and  also  the  tracheal  and 
laryngeal  mucous  membrane.  It  runs,  as  a  rule,  an  afeb- 
rile course  accompanied  by  moderate  itching  and  termi- 
nating in  from  two  to  six  weeks. 

Erythema  Nodosum  (Dermatitis  Contusiformis). — Ca|>- 
illary  stasis  in  and  beneath  the  skin  of  the  backs  of  both 
feet  and  legs,  more  rarely  of  the  thighs,  nates,  and  upper 
extremities,  leads  to  the  formation  of  dense,  painful 
swellings  and  nodules  about  the  size  of  a  hazel-nut. 
Their  a])pearance  is  accompanied  by  gastric  disturbances 
and  swelling  and  painfulness  of  the  joints.  The  skin 
covering  the  papules  is  rose  red  in  color,  but  in  from  two 
to  three  days  shows  the  gradual  development  of  the  same 
]day  of  colors  seen  in  the  eruption  of  er\'thema  exuda- 
tivum  multiforme.  The  papules  undergo  resolution  in 
from  eight  to  fourteen  days,  yet  the  appearance  of  fresh 
crops  of  eruption  may  prolong  the  disease  over  six  weeks 
or  more. 

Treatment. — There  is  no  especial  treatment  for  erythe- 
ma exudativum  multiforme.     To  allay  the  itching  employ 


428  DISEASES  OF  THE  SKIN 

menthol  or  carbolic  acid,  1.0  gm.,  to  spiritus  vini  gullici, 
150.0  cc.  Erythema  nodosum  requires  rest  in  bed,  cool 
applications,  and  the  administration  of  the  salicylates  for 
articular  pains. 

LICHEN  URTICATUS 
{Slrophidris,  Toolhrrash) 

Lichen  urticatus  is  an  angioneurotic  eruption  accom- 
panied by  much  itching  and  developing  frequently  at  the 
time  of  the  first  dentition  ("tooth-rash");  in  the  latter 
case  it  is  probably  excited  reflexly  from  the  dental  nerves. 
It  occurs,  however,  also  in  children  who  are  not  teething, 
practically  so  only  in  the  second  period  of  childhood,  from 
as  yet  unknown  causes  (in  many  cases  it  can  be  referred 
to  an  insect  bite). 

Symptoms. — Without  any  constitutional  disturbance 
various  parts  of  the  body,  especially  the  neck,  lower 
extremities,  soles  of  the  feet,  and  the  palms  of  the 
hands,  become  covered  with  red  specks  which  rapidly 
grow  into  wheals  the  size  of  a  lentil  seed.  Their  centers 
fade  and  assume  the  appearance  of  wax-like  vesicles 
(similar  to  varicella) ;  they  are,  however,  distinguished 
from  vesicles  by  their  extremely  dense,  horn-like  con- 
sistency. Tile  excessive  itching  causes  the  eruption  to  be 
scratched  sore.  The  repeated  occurrence  of  fresh  eruptions 
may  prolong  the  disease  over  weeks,  months,  and  even 
years. 

Treatment. — Anoint  with  remedies  whicli  will  relieve 
the  itching,  such  as  1  to  2  })er  cent,  carbolic  acid  solution 
or  menthol,  1.0  gm. ;  glycerin,  3.0gm. ;  spiritus  vinigal- 
lici,  150.0  cc,  and  spiritus  setheris,  15.0  cc.  Apply  bland 
dusting-powders  to  the  areas  which  are  still  moist.  In 
obstinate  cases  administer  a  laxative. 

URTICARIA 

Urticaria  is  a  disease  belonging  to  the  angioneurotic 
forms  of  dermatoses  and  is  characterized  by  the  develop- 
ment of  wheals.  It  develops  suddenly,  following  certain 
internal  and   external    forms   of  irritation,    vaccination. 


LICHEN  SCROFULOSORUM  '  429 

insect  bites,  burns,  dyspepsia,  intestinal  parasites,  certain 
foods  (strawberries),  and  psychic  influence,  and  disap- 
pears rapidly  in  a  few  hours  or  days,  accompanied  by 
moderate  scaling  of  the  skin,  and  occasionally  leaving 
yellow  specks  behind. 

Ssrmptoms. — The  wheals,  which  are  circumscribed  eleva- 
tions of  the  skin  due  to  the  collection  of  a  serous  fluid  in 
the  rete,  are  white  or  rose  red  in  color  and  surrounded  by 
a  red  areola.  They  vary  in  size  from  a  lentil  seed  to  that 
of  a  twenty-five-cent  piece,  and  tend  frequently  to  coalesce 
into  extensive  irregular  figures.  The  face  and  joints  are 
attacked  by  preference  (when  localized  in  the  orbital 
region  no  wheals  develop,  but  the  lids  are  red  and  edema- 
tous). The  appearance  of  wheals  is  associated  with  itch- 
ing or  burning,  which  increases  when  resting  in  bed. 
Fever  is  occasionally  present.  Recurrences  are  especially 
frequent  in  nervous  subjects. 

Treatment. — When  possible  remove  the  cause.  Locally 
apply  cooling  lotions  and  the  salicylates  in  the  powder 
form.  [Laxatives  are  indicated  in  the  persistent  forms.r 
Belladonna  or  atropin  in  minute  doses  brings  relief. — Ed.] 

LICHEN    SCROFULOSORUM 

Scrofulous  children,  especially  at  the  age  of  puberty, 
occasionally  develop  gradually  and  un noticeably  an  erup- 
tion which  itches  but  slightly  and  consists  of  flat,  pale 
red  or  yellowish-brown  papules.  The  latter  vary  in  size 
from  a  millet  seed  to  a  pin's  head,  are  but  slightly 
resistent,  and  possess  a  scaly  summit.  They  are  arranged 
in  groups  or  in  circles,  chiefly  upon  the  trunk,  less  rarely 
upon  the  extremities,  and  remain  unaltered  for  months, 
after  which  they  gradually  fade  and  undergo  resolution 
accompanied  by  moderate  exfoliation.  Anatomically  the 
local  process  consists  of  a  cellular  infiltration  and  exuda- 
tion in  the  neighborhood  of  the  orifices  of  the  hair- follicles 
(Kaposi).  The  cause  of  this  condition  is  scrofula,  and 
other  symptoms  of  that  disease  are  always  present,  espe- 
cially  marked   lymphatic   swelling.    (Since   the  genetic 


430  DISEASES  OF  THE  SKIN 


PLATE  47 

Lichen  Scrofulosorum. — A  girl  nine  years  old  presented  the  typic 
symptoms  of  scrofula,  including  chronic  conjunctival  and  nasal  catarrh 
and  swelling  and  hardening  of  the  cervical  and  axillary  nodes.  An 
eruption  is  seen  on  the  skin,  chiefly  on  the  trunk,  which  during  the  two 
months  of  its  existence  has  undergone  no  noticeable  change.  Innumer- 
able pale,  brownish,  millet-seed-sized  flat  papules  are  seen  irregularly 
grouped  and  partly  arranged  in  continuous  lines  and  crescents.  Single 
papules  are  also  noted  on  the  skin  of  the  upper  arms  and  thighs.  Slow 
recovery  followed  the  external  and  internal  use  of  cod-liver  oil. 


relationship  between  scrofula  and  tuberculosis  has  been 
more  thoroughly  studied  there  has  been  a  tendency  to 
also  call  lichen  scrofulosorum  miliary  tuberculosis  of 
the  skin.) 

Cliief  Characteristics. — Appearance  of  homogeneous, 
pale-red  or  yellowish-brown  soft  papules  covered  cen- 
trally by  scales,  which  occur  in  groups  or  arc  arranged  in 
circles.  They  attack,  as  a  rule,  only  the  trunk  and  per- 
sist for  weeks  and  months  without  undergoing  conversion 
into  vesicles  or  pustul/ss.  Accompanied  by  symptoms  of 
scrofula. 

Treatment, — Oil  the  dry,  papular  skin  with  cod-liver 
oil  two  or  three  times  a  day.  Treat  as  in  case  of 
scrofula. 

HERPES 

Herpes  is  an  ephemeral  eruption  of  a  grouj)  of  vesicles 
on  the  face  or  on  the  genitalia,  and  spreads  independently 
of  the  course  of  the  nerves.  It  is  a  frequent  concomi- 
tant to  febrile  di.sea.ses,  but  arises  also  in  healthy  children 
without  a  demonstrable  cause. 

Symptoms. — Pin-head-sized  vesicles  which  rapidly  coa- 
lesce appear  with  a  moderate  burning  sensation  and  itch- 
ing on  a  section  of  skin  previously  reddened.  They  are 
clear  as  water  and  are  arranged  cither  in  round  or  irreg- 
ularly formed  groups.  In  one  or  two  days  they  become 
turbid  and  purulent,  followed  by  desiccation  and  the  for- 
mation of  scabs.  Healing  occurs  within  a  week.  The 
diagnosis  is  easily  made,  even  when  the  vesicles  coalesce 


7hbA 


SCABIES  431 

or  when  the  scabs  are  lost  (through  macferation  or  scratch- 
ing), by  the  constant  circular  form  of  the  eruption. 

Treatment. — Bland  dusting- powders  ;  for  marked 
swelling  make  applications  with  aluminum  acetate  (1 
tablespoonful  to  1  pint  of  water). 

SCABIES 

{Ilch) 

Scabies  is  an  itching  eruption  caused  by  the  presence 
of  the  itch-mite  (Acarus  scabiei),  which,  burrowing  itself 
in  the  skin  as  deep  as  the  rete,  causes  eczematous  clianges. 
The  mite,  which  is  transmitted  by  contact,  attacks  by 
preference  the  interdigital  folds,  the  flexor  surface  of  the 
wrist,  elbow,  and  knee-joints,  the  gluteal  and  axillary 
folds,  the  prepuce,  and  in  children  also  the  palms  of  the 
hands  and  soles  of  the  feet.  The  disease  may  spread 
further  from  these  central  sites,  but  the  head  always  re- 
mains uninvolved.  The  burrows  appear  in  the  hands 
and  feet  as  irregularly  curved  whitish  lines  dotted  with 
dark  points.  In  other  regions  they  are  represented  by 
long  papular  reddened  elevations,  the  surface  of  which 
appears  as  if  scratched  with  a  needle.  The  point  at 
which  the  mite  enters  the  epidermis  is  marked  by  a  small 
])ustule  or,  after  it  has  died,  by  a  pear-shaped  epidermal 
exfoliation.  The  mite  lies  at  the  end  of  the  burrow  and 
may  be  recognized  macroscopically  as  a  whitish-yellow 
point  glistening  through  the  corneum.  The  dark  and 
almost  black  points  in  the  burrows  are  the  feces  of  the 
mite.  The  eczema  (papular,  vesicular,  and  pustular  for- 
mation) is  partly  primary,  due  to  the  activity  of  the  mite, 
and  partly  secondary,  due  to  scratching  on  account  of  the 
intense  itching. 

Chief  Characteristics. — Itching  of  the  skin,  which  is 
increased  by  the  warmth  of  the  bed.  A  peculiar  tyj>o  of 
eczema  which  predominates  in  the  areas  of  predilection, 
the  flexor  surfaces  of  the  joints,  from  which  the  face  as  well 
as  the  head  is  exempt,  and  wiiich  consists,  almost  without 
exception,  of  isolated  eruptions  which  do  not  spread  to  a 
larger  eczematous  area  until  the  lapse  of  a  long  time. 


432  DISEASES  OF  THE  SKIN 

PLATE  48 

Scabies. — A  minute  papular  aud,  iu  some  areas,  pustular  eczema, 
causing  itching,  developed  on  the  whole  body  with  the  exception  of  the 
head,  in  a  girl  thirteen  years  old,  whose  sisters  suffered  from  the  same 
affection.  The  eruption,  which  occurs  maiuly  in  isolated  areas,  shows 
much  scratching  and  is  covered  with  bloody  scabs.  The  eczema  is  most 
marked  in  the  flexures  of  the  joints.  The  picture  of  the  hands  shows 
the  eruption  following  chiefly  the  interdigital  folds  and  deeper  skin 
furrows.  The  first  hand  shows  several  burrows  (not  well  reproduced). 
The  disease  has  existed  for  two  weeks.  Recovery  in  five  days  by 
means  of  energetic  rubbing  with  a  sulphur  ointment. 


Mite-burrows,  which  are  especially  prominent  and  nu- 
merous in  the  locations  of  predilection. 

Treatment. — Destroy  the  mite  and  its  eggs  and  after- 
ward cure  the  eczema.  To  fulfil  the  first  demand  rub 
energetically  with  [Wilkinson's  ointment :  Precipitated 
calcium  carbonate,  10  parts  ;  sublimed  sulphur,  15  parts  ; 
oil  of  cade,  15  parts  ;  soft  soa]>,  30  parts  ;  lard,  30  parts. 
— Ed.],  to  be  repeated  on  four  successive  days  (painful 
but  radical  cure).  Give  a  cleansing  bath  on  the  fifth  day 
and  put  on  fresh  body-  and  bedclothes.  Future  baths  are 
to  be  limited  on  account  of  the  eczema. 


PEDICULOSIS  CAPILLITII 

Pediculosis  capillitii  is  pre-eminently  an  impetiginous 
eczema  of  the  scalp  which  is  caused  by  the  head-louse 
(Pediculus  capitis),  and  which  is  frequently  accompanied 
by  swelling  of  the  lymph-nodes  with  the  formation  of 
abscesses.  Insomnia  on  account  of  the  itching.  Anemia. 
Diagnosis  is  established  by  the  discovery  of  the  lou.so  or 
by  its  eggs,  which  are  found  adhering  to  the  hair.  Dis- 
seminated eczematous  pustules  at  the  edge  of  the  scalj) 
are  always  suspicious. 

Treatment. — To  kill  the  lice  rub  the  head  with  petro- 
leum, but  in  case  of  pronounced  inflammation  it  is  wiser 
to  employ  a  10  ]>er  cent,  white  precipitate  ointment. 
The  nits  may  be  removed  l)y  combing  the  hair  with  a 
fine  comb  which  has  been  immersed  in  acetic  acid.  Treat 
the  eczema. 


TabM 


FOLLICULITIS  ABSCEDENS  433 

HERPES  TONSURANS 

Herpes  tonsurans  is  a  contagious  itching  eruption 
caused  by  the  Trichophyton  tonsurans.  It  is  character- 
ized by  the  presence  <  n  the  scalp  of  bald  areas  covered 
with  stubs  of  hair  and  scales  varying  in  size  from  a 
penny  to  a  silver  dollar,  which  are  surrounded  by  ery- 
thematous or  circularly  arranged  fresh  or  dried  vesicles. 
Herpes  tonsurans  vesiculosis  occurs  on  the  non-hairy 
parts  of  the  body  and  consists  of  rings  of  vesicles  which 
surround  a  red  and  scaly  or  pale  central  area.  Herpes 
tonsurans  maculosus  occurs  more  commonly  than  the 
latter  and  is  characterized  by  a  maculopapular  eruption 
which  spreads  centrifugally  and  which  fades  and  des- 
quamates at  the  center.  The  diagnosis  is  made  certain 
by  the  discovery  of  the  myces  and  the  gonidei  in  the 
stubs  of  hair  or  in  the  epidermal  scales. 

Treatment. — Vigorous  rubbings  with  alcohol,  followed 
by  the  application  of  5  per  cent,  naphtol  ointment. 
Epilation  may  be  necessary  for  herpes  tonsurans  cap- 
illitii. 

FOLLICULITIS  ABSCEDENS  (ESCHERICH) 

( Pseudofuruncvlogii) 

The  formation  of  multiple  abscesses  in  the  skin  occurs 
not  rarely  in  badly  nourished,  anemic,  and  atrophic 
children,  "in  whom  tlie  skin  shows  an  abnormally  low  tone, 
and  also  in  overfed  children.  The  abscesses  are  due  to 
the  invasion  of  pyogenic  staphylococci  into  the  sweat  and 
sebaceous  glands.'  They  occur  often  in  large  numbers 
(twentv,  fiftv,  or  more),'esiX!cialIy  in  the  scalp,  back,  and 
h)wer  extremities.  At  first  we  note  lentil-  to  pea-sized 
fairlv  indolent  papules  underneath  the  slightly  re<ldened 
skin!  If  the  papules  develop  to  the  size  of  a  hazel-nut 
the  skin  which  covers  them  is  of  a  livid  red  color,  thin, 
and  allows  pus  to  shine  through  it.  In  about  one  week 
spontaneous  rupture  occurs  and  the  pus  escajH-s,  after 
which  rai)id  healiuir  sets  in.  (The  abscesses  contain  pus 
only,  ami  at  no  time  necrotic  tissue.)     Occasionally  reso- 

28 


434 


DISEASES  OF  THE  SKIN 


Fig.  146. — Skin  parasites,  a.  Nits  attached  to  the  shafts  of  the  hair. 
6.  Pediculus  capitis,  c.  Clothes-louse,  d.  Pediculus  jiubis.  e.  A  sca- 
bies burrow.  /.  The  egg  of  the  Acarus  scabici.  g.  Itcli-iuite  seen  from 
below,  h.  Itch-mite  seen  from  above,  i.  Tricliophyton  tonsurans  (hair 
with  its  outer  root-sheath,  from  a  case  of  lierpes  tonsurans  cai)itis). 
(Mracek,  Atlas  of  Skin  Diseases.) 

Intion  occurs  without  suppuration.      The  repeated  occur- 
rence of  fresh  crops  of  the  eruption   may  prolong  the 


Fig.  147. — Pseudofurunculosis  in  an  eight-months'-old  poorly  iiourislied 
infant  who  sufl'ered  from  chronic  disturbances  of  digestion. 

disease  considerably.     The  constitutional  symptoms  de- 
pend upon  the  causal  disease. 

Treatment. — Treat  the  etiologic  factor.      Improvement 
follows  a  reduction  in  diet  in  some  cases.      Many  of  the 


SKIN  PARASITES 


435 


Fig.  146. 


436  DISEASES  OF  THE  SKIN 

abscesses  recede  upon  the  application  of  aluminum  ace- 
tate. The  matured  abscesses  are  pierced  with  a  small 
point  and  carefully  emptied,  but  not  before  the  neighbor- 
ing skin  has  been  protected  against  the  infection  with  the 
cocci-containing  pus  by  anointing  with  a  bland  ointment. 
The  abscesses  which  have  been  operated  upon  are  covered 
with  a  moist  dressing  (aluminum  acetate).  Sublimate 
baths  arc  rocommeuded  for  extensive  pseudofurunculosis 
(1  tablet  to  a  bath). 


INDEX 


Abdominal  purpura,  147 

tuberculosis,  184 
Abscess,  brain,  217 

retropharyngeal,  353 
Achondroplasia,    congenital,    130, 

132 
Acid-fermentation  dyspepsia,  361 
Acrania,  90 

Adenoid  vegetations,  349 
diagnosis,  353 
treatment,  353 
Adipose  tissue,  28 
Agonal  invagination,  380 
Air-passages,  foreign  bodies  in,  322 
Albumin  content  of  milk,  dimin- 
ishing, 46 
Albuminuria,  385 

cyclic,  387 

intermittent,  387 

orthotic,  387 

transitory,  387 
Alimentary  disturbances,  355 
Alterants,  73 

Amaurotic  idiocy  of  families,  249 
Amvloid  degeneration  of  kidneys, 

391 
Anamnesis,  50 

in  diseases  of  digestive  tract,  51 
of  metabolism,  50 
of  respiratory  trad,  51 

in  herinlitary  syphilis,  50 

in  nervous  diseases,  50 

in  rachitis,  50 
Anatomic  peculiarities,  17 
Anemia,  149 

cerebral,  209 

feeding  in,  150 

hydrotherapy  in,  151 

splenic,  151 

treatment,  150 


Angina,  347 

catarrhal,  347 

diagnosis,  348 

lacunar,  347 

pi-ophylaxis,  349 

symptoms,  347 

treatment,  349 

ulcerosji,  344 
Angioma  cavemosum,  408 

simplex,  408 
Anomalies,  congenital,  of  heart,  303 
Antitoxin  treatment  of  diphtiieria, 

281 
Anus,  atresia  of,  in  newborn,  107 
Aphthffi,  Bednar's,  342 
Aphthous  stomatitis,  343 
Appendicitis,  375 
Applications,  70 
Arteries,  umbilical,  86 
Arthritis  fungosa,  195 
Ascaris  lumbricoides,  381 
Aspiration  pneumonia,  329 
Asthma,  bronchial,  323 

nervous,  323 
Astringents,  73 
Ataxia,  hereditarv,  230 

Friwlreich's,  230 
Athetosis,  224 
Atonv  of  stomach  and   intestines, 

374 
Atresia,  cellular,  of  vulva,  403  ^ 

congenital,   of    gastro-inteslinal 
tract,  375 

of  anus  in  newbom,  107 
Atn)phia  infantum,  366 

constipation  in,  treatment,  372 
«liot  in,  371 

gastrt)-inttistinal    disi-asi'S     in, 
prophylaxis,  367 
treatment,  369 

437 


438 


INDEX 


Atrophia  infantum,  medication  in, 
372 
prolapse  of  rectum   in,  treat- 
ment, 373 
Atrophy,  juvenile  muscular,  Erb's 

form  of,  251 
Auscultation,  63 

of  heart-sounds,  304 
Auscultatory  percussion,  66 

Bacteria  in  milk,  freeing,  45 
Balanoposthitis,  398 
Barlow's  disease,  137 

treatment,  138 
Basetlow's  disease,  139 
Baths,  cold-water,  71 

cool,  70 

hot,  70 

warm,  70 
Bednai-'s  aphthae,  342 
Biedert's   injurious  food  remnant, 

a59 
Birth,  premature,  75 
Black  small-pox,  269 
Bladder,  diseases  of,  395 

ectopia  of,  in  newborn,  107 

invei-sion  of,  in  newborn,  107 

prolapse  of,  in  newborn,  107 
Blennorrhea  neonatorum,  88 

treatment,  89 
Blood,  33 

circulation,  33 
Blood-tumor  of  head  in  newborn, 
94 
treatment,  95 
Bloo<l- vessels,  diseases  of,  312 
Bloody  operation  in  diphtheria,  286 
Bone,  apposition  of,  in  rachitis,  124 

connective-tissue,  in  rachitis,  125 

development,  congenital  disturb- 
ances in,  130 
Bones  and  joints,  tuberculosis  of, 
194 

direct  percussion,  63 

in  hereditary  syphilis,  154 

prefoiTued  in  cartilage  in  rachitis, 
122 
Brain  abscess,  217 

anemia  of,  209 

circulatory  disturbances  of,  208 

diseases  of,  204 


Brain,  hyperemia  of,  208 
active,  208 
passive,  209 
tumore  of,  224 
Breast  feeding,  43 
Bronchial  asthma,  323 
nodes,  tuberculosis  of,  173 
morbid  anatomy,  173 
symptoms,  173 
Bronchiectasis,  335 
Bronchitis,  acute,  324 

morbid  anatomy,  324 
symptoms,  324 
treatment,  325 
capillary,  326 
diagnosis,  328 
morbid  anatomy,  326 
prognosis,  327 
symptoms,  327 
treatment,  328 
chronic,  326 
Bronchopneumonia,  328 
diagnosis,  331 
morbid  anatomy,  329 
symptoms,  330 
treatment,  332 
Brown-Sequai-d  paralysis,  229 

Calcitli,  vesical,  393 
diagnosis,  394 
prognosis,  394 
symptoms,  393 
treatment,  394 
Calories  pi-oduced  by  various  forms 

of  nourishment,  42 
Capillary  bronchitis,  326.     See  also 

Bronchiii.t,  capillary. 
Caput  quadratum,  114 
Cai-diac-pulmonary  murmur,  304 
Cardiants,  74 

Caries,  tuberculous,  of  vertebra?,  196 
results,  198 
symptoms,  197 
treatment,  198 
Caseous  pei-ibronchitis  in  pulmon- 
ary tuberculosis,  181 
pneumonia  in  pulmonary  tuber- 
culosis, 182 
morbid  anatomy,  181 
Catarrh,  intestinal,  361 
Catarrhal  angina,  347 


INDEX 


439 


Catarrhal  stomatitis,  342 
Cellular  alrt'sia  of  vulva,  403 
Ceplialheniatoina  of  newborn,  94 
Cerebral  anemia,  209 
infantile  palsy,  217 
diagnosis,  224 
dir)legic  type,  220 
etiology,  218 
hemiplegic  type,  218 
morbid  anatomy,  218 
symptoms,  218 
treatment,  224 
sinuses,  inflammatory  thrombosis 
of,  207 
marantic  thrombosis  of,  207 
thrombosis  of,  207 
Cerebrospinal     canal,     incomplete 
closure  of,  in  newborn,  96 
fluid,  examination,  67 
meningitis,  204 
course,  205 

epidemic,  diagnosis,  193 
treatment,  205 
Cervical  fistula,  congenital,  105 
Chest  measurements,  29 
Chicken-pox,  273.     See  also   Vari- 
cella. 
Chlorosis,  150 
feeding  in,  150 
hydrotherapy  in,  151 
treatment,  150 
Cholera  infantum,  362 
Chorea,  electric,  241 
general  infantile,  223 
major,  246 
minor,  240 
course,  242 
diagnosis,  242 
etiology,  240 
morbid  anatomy,  240 
muscle  anarchy  in,  241 
prognosis,  242 
symptoms,  241 
treatment,  242 
paralytic,  241 
Chvostek's  sign  of  tetany,  235 
Circulation,  fetal,  17 

of  blood,  33 
Circulatory  apparatus,  diseases  of, 
303 
general  considerations,  303 


Cleft  palate,  104 
Cold  sprays,  71 
Cold-water  baths,  71 
Colicystitis,  396 

treatment,  397 
Colitis,  364 

dysenteriformis,  364 
Colles'  law,  152 
Colostrum,  39 
Compression  myelitis,  229 
Concretions,  urinary,  391 
Confluent  variola,  269 
Conjunctiva,   secretions  from,  ex- 
amination, 67 
Conjunctivitis,  diphtheritic,  279 
Connective-tissue  bone  in  rachitis, 

124,  125 
ConstijKition,  habitual,  354 

in  atrophia  infantum,  treatment, 
372 
Constitutional  diseases,  114 
Convulsions,  230 

salaam,  239 
Cool  baths,  70 
Coryza,  315 
Coxitis,  198 

treatment,  201 
Craniorrachischisis,  99 
Cranioschisis,  96 
Craniotahes  in  rachitis,  114 
Cretinism,  sporadic,  140 
Croup,  278 

Croupous  pneumonia,  333 
differential  diagnosis,  334 
prognosis,  335 
treatment,  335 
Crusta  lactca,  421 
Cryptorchism,  402 
Cutis  scbacea,  411 
Cystitis,  390 

chief  characteristics,  397 

treatment,  397 
Cystolithiasis,  393 

Deafnf¥8,  35 

Defonnities  of  extremities  in  new- 
born, 108 
Degeneration,  amyloid,  of  kidneys, 
391 
fatty,  of  heart,  311 
symptoms,  312 


440 


INDEX 


Degeneration,  fatty,  of  heart,  treat- 
ment, 312 
Dentition,  36 
Dermatitis  contusiformis,  427 

exfoliativa,  415 
symptoms,  415 
treatment,  417 
Dermoid  spaces  in  newborn,  96 
Desiccation  fever  of  variola,  268 
Diaphoretics,  74 
Diarrhea,  fat,  361 
Diathesis,  hemorrhagic,  146 
Diet  in  atropiiia  infantimi,  371 

in  rachitis,  130 
Dietetic   treatment   of    disease    in 

children,  68 
Digestion,  37 

fat,  marked  insufficiency  of,  361 
Digestive  organs,  diseases  of,  342 

tract,  diseases  of,  anamnesis  in, 
51 
Diphtheria,  275 

and  scarlet  fever,  differentiation, 
265 

beginning,  276 

bloody  operation  in,  2S6 

cause,  275 

complications,  280 

constitTitional  treatment,  283 

course,  276 

diagnosis,  281 

extubation  in,  286 

fibrinous  exudate  in,  275 

gravis,  278 

intubation  in,  285 

laryngeal,  278 

local  treatment,  283 

nasal,  279 

of  vulva,  279 

pharyngeal,  277 

prognosis,  280 

septic,  278 

sequelae,  280 

serum  treatment,  281 

special  treatment,  283 

specific  treatment,  281 

symptom-complex,  276 

symptoms,  276 

tracheotomy  in,  286,  290 

treatment,  281 
Diphtheritic  conjunctivitis,  279 


Dislocation,     congenital,   of     hip- 
joint,  112 
iliac,  112 

supracotyloid,  112 
and  iliac,  112 
Diuretics,  74 

Diverticulum,    Meckel's,  in    new- 
bom,  107 
Dosjige,  72 

Drinks  for  sick  children,  69 
Dry  pleurisy,  338 
Duchenne's  paralysis,  250 
Dulness,  absolute  cardiac,  304 

relative  cardiac,  304 
Dyspepsia,  360 
acid-fermentation,  361 
following  disturbances  of  fermen- 
tation, 361 
Dysthyroidism,  139 

Ear  in  scrofula,  178 
Eclampsia,  230 

diagnosis,  232 

etiology,  231 

functional,  231 

infantum,  230 

prognosis,  232 

secondary  symptomatic,  231 

symptoms,  231 

treatment,  233 
Ecthyma,  419,  422 

cachecticorum,  422 

pustules  in  scrofula,  177 
Ectopia  of  bladder  in  newborn,  107 

testis,  400,  402 
Eczema,  419 

chief  characteristics,  420 

chronic  impetiginous,  in  scrofula, 
177 

course,  420 

crustosum,419 

cyclic,  419 

death,  420 

erythematosum,  419 

impetiginosum,  419 

intertrigo,  421 

madidans,  419 

papulosum,  419 

prognosis,  420 

pustulosum,  419 

squamosum,  419 


INDEX 


441 


Eczema  sudamen,  421 

symptoms,  411) 

treatment,  423 

vesiculosum,  419 
Elbow,  tuberculosis  of,  203 
Electric  chorea,  241 
Emetics,  73 
Em[)yenia,  337 

ichorous,  337 
Encephalitis,  217 

acute  non-suppur;itive,  217 
suppurative,  217 
Endocjinlitis,  309 

diagnosis,  310 

prognosis,  310 

symptoms,  309 

treatment,  310 
Endochondral    ossification    in    ra- 
chitis, 122,  125 
Energy-quotient,  42 
Enlargement  of  spleen  and  liver  in 

hereditary  syphilis,  153 
Enuresis,  395 

treatment,  396 
Epilepsy,  242 

coui"se,  244 

diagnosis,  244 

etiology,  242 

Jacksonian,  243 

prognosis,  244 

reflex,  242 

symptoms,  243 

treatment,  244 
Epileptic  vertigo,  248 
Epispadias,  400 

Epitlielial  adhesion,  preputial,  398 
Erb's   form  of   juvenile   muscular 
atrophy,  2ol 

sign  of  tetjiny,  235 
Ervthema  and  measles,  differentia- 
tion, 260 

exudativum  midtiforme,  426,  427 
treatment,  427 

nodosum,  426,  427 
treatment,  427 
Escherich's  pseudotetanus,  236 
Eversbusch's   arm  bandage  in  ec- 
zema, 424 
Examination,  49 

projier  method,  51 
Excretion  of  urine,  35 


Excretions,  67 
t;xi)ectorants,  72 
Extremities,  anatomy,  22 

deformities  of,  in  newborn,  108 

in  rachitis,  119 
Extubiition  in  diphtheria,  286 
Eyes  in  scrofula,  178 

Facial  defects  in  newborn,  lOS 

nerve  phenomenon  of  tetany,  235 
Fat  content  of  milk,  loss  of,  46 

diarrhea,  361 

digestion,  marked  insufficiency  of, 
361 
Fatty  degeneration  of  heart,  311 
symptoms,  312 
treatment,  312 
Feces,  examination,  67 

I)ea-soup,  in  typhoid  fever,  292 
Feeding,  artificial,  44 

breast,  43 

in  anemia  and  chlorosis,  150 

natural,  39 

premature  children,  76 
Feet,  joints  of,  tuberculosis  of,  203 
Female  genitals,  28 
Feniientation,  dys})e[)sia  following 

disturbances  of,  361 
Fetal  circulation,  17 

myxedema,  130,  136 

rachitis,  130 
Fibrinous  ])neunionia,  333 
Finger-naii-on-finger-nail     method 

of  percussion,  6() 
Finger-f)n-finger  meth(xl  of  j>ercu8- 

sion,  66 
Fingers,  abnormal   numl>or  of,   in 

newborn,  108 
Fish-scale  disease,  411 
Fistula,  cervical,  congenital,  105 
Flat-foot  in  newborn,  112 
Folliculitis  abscedens,  433 

treatment,  434 
Fontanels,  anomalous,  96 
Food,  anuiunt  of,  required  by  nurs- 
ling, 42 
Foreign  bo<lies  in  air-jmssages,  322 
Foreign-lxxly  pneumonia,  329 
Friedreich's  ataxia,  230 
Fulminating  purnnra,  148 
Fungus,  umbilical,  84 


442 


INDEX 


Gangrene  of  umbilicus,  85 

of  vulva,  405 
Gastric  lavage,*  369 
Gastro-eiUeritis,  3G4 
Gastro-intestinal  diseases,  354 
etiology,  354 

from  improper  nursing,  359 
general  discussion,  354 
in  atrophia  infantum,  prophy- 
laxis, 307 
treatment,  369 
symptoms,  360 
tract,  congenital  atresia  of,  375 
stenoses  of,  375 
Genitals,  female,  28 
Genito-urinary    tract,  diseases  of, 

385 
Gibbus,  196 
Glandular  fever,  313 
Glottis,  spasm  of,  236 
Gonorrheal   vulvovaginitis,    treat- 
ment, 404 
Growth  in  length,  28 

Habitual  constipation,  354 

vomiting,  354 
Hand,  obstetric,  234 
Hare-lip,  103 

Head,  blood-tumor  of,  in  newborn, 
94 
treatment,  95 
measurements,  30 
Hearing,  35 

Heart,    congenital    anomalies    of, 
303 
disease,  congenital,  diagnosis,  305 

treatment,  307 
diseases  of,  303 
diagnosis,  304 
symptoms,  303 
dulness  of,  absolute,  304 

relative,  304 
fatty  degeneration,  311 
symptoms,  312 
treatment,  312 
murmurs,   accidental  inomanic, 
305 
Heart-sounds,  auscultation  of,  304 
Hebephrenia,  250  • 

Heckei-'s  urine  vessel,  385 
Hematuria,  387 


Hemiplegia,  spastic  infaptile,  218 
Hemoglobinuria,  387 

acute,  of  newborn,  94 
Hemorrhage,  umbilical,  84 
Hemorrhagic  diathesis,  146 
pleurisy,  337 
purpura,  147 
rachitis,  acute.  137 
Henoch's  purpura,  147 
Heredosyphilis,  152 
Hernia,  umbilical,  acquii-ed,  81 
treatment,  82 
congenitiil,  81 
funicular,  81 
Herpes,  430 
symptoms,  430 
tonsurans,  433 
treatment,  431 
Heubner's    two-thirds    milk    mix- 
ture, 46 
Hip-joint,  congenital  luxation,  112 
iliac,  112 

supracotyloid,  112 
and  iliac,  112 
Hirschsprung's  disease,  354 
Histoi-y,  49 
Hot  baths,  70 

stupes,  71 
Hutchinson's  triad,  158 
Hydrocele,  402 

communicans,  402 
Hydrocephaloid,  209 
Plydrocephalus,  acute,   187.      See 
also  Meningitis,  tuberaUous. 
chronic,  209 
coui-se,  214 
diagnosis,  217 

disturbances  of  motion,  214 
etiology,  211 
morbid  anatomy,  211 
symptoms,  211 
ti-eatment,  217 
externus,  209 
intemus,  209 
intnimeningealis,  211 
Hydronephrosis,  395 
Hydropathic  applications,  70 
Hydrotherapy,  69 

in  anemia  and  chlorosis,  151 
Hygroma,  congenital,  of  neck,  105 
Hyperemia  of  brain,  208 


INDEX 


443 


Hyperemia  of  brain,  active,  208 

passive,  209 
Hyperplasia    of    lymph-tissue    of 
pharynx,  349 
diagnosis,  353 
treatment^  353 
of  thymus  gland,  322 
Hvpertrophy   of    tongue   in   new- 
born, 105 
Hypospadias,  400 
Hypothyroidism,  139 
chronic  benign,  139 
treatment,  145 
Hysteria,  246 
coui-se,  247 
diagnosis,  247 
prognosis,  247 
symptoms,  246 

Ichthyosis,  411 
ctmgenital,  411 
diagnosis,  412 
folhcularis,  412 
palmaris  et  plantaris,  412 
prognosis,  412 
symptoms,  412 
treatment,  412 
Icterus,  383 

neonatorum,  33 
Idiocy,  amaurotic,  of  families,  249 

treatment,  250 
Imbecility,  249 
Impetigo  contagiosa,  421 
Incubator  room,  76 
Infantilism,  140 
Infarcts,    uric-acid,     in     newborn, 

391 
Infectious  diseases,  acute,  252 
general  discussion,  252 
period  of  incubation,  252 
prodromal  symptoms,  253 
chronic,  152 
Inflammations,  intestinal,  chronic, 
365 
morbid  anatomy,  363 
sequeUp,  303 
Inflammatory  thrombosis  of  cere- 
bral sinuses,  207 
Influenza,  294 

bronchial  phenomenon  in,  295    > 
diagnosis,  295 


Influenza,  duration,  295 

prognosis,  295 

pulmonary  phenomenon  in,  295 

i-etropharyngitis  in,  294 

symptoms,  294 

ti-eatment,  295 
Insanity,  250 

moral,  250 
Inspection,  55 

Intermittent  albuminuria,  387 
Intestinal  catarrh,  361 

inflammation,  363 
chronic,  365 
morbid  anatomy,  363 
sequelae,  363 

invagination,  380 

lavage,  369 

parasites,  380 
diagnosis,  380 
Intestines,  anatomy  of,  24 

atony  of,  374 

tuberculosis   of,  184.     See  also 
Tuberculosis  of  iiUestines. 
Intubation  in  diphtheria,  285 

tubes,  286 
Invagination,  agonal,  380 

intestinal,  380 
Inversion  of  bladder  in  newborn, 

107 
Itch,  431 

Jacksontan  epilepsy,  243 
Jaundice,  383 

Joints  and  bones,  tuberculosis  of, 
194 
of  feet,  tubereulosis  of,  203 

Keratoconjunctivitis,  phlycten- 
ular, in  scrofula,  treatment,  180 

Kei-nig's  sign,  190 

Kidneys,  amyloid  degeneration  of, 
391 
anatomy,  23 
contracted,  391 
disejises  of,  385 
diagnosis,  385 
in  hei-editary  syphilis,  154 
lardaceous,  391 
large  white,  391 
swollen,  391 

Knee,  white  swelling  of,  201 


444 


INDEX 


Knee-joint,  tuberculosis  of,  201 

treatment,  202 
Koplik's  spots,  257 

Lacunar  angina,  347 
Lardaceous  kidney,  391 
Laryngeal  diphtheria,  278 
Laryngismus  stridTilus,  236 
Laryngitis,  acute,  318 

differential  diagnosis,  319 
symptoms,  318 
treatment,  320 
Laryngospasm,  236 
coui-se,  238 
diagnosis,  238 
of  tetany,  235 
prognosis,  238 
symptoms,  236 
treatment,  238 
Larynx,  papilloma  of,  322 
Lavage,  gastric,  369 

intestinal,  369 
Laxatives,  72 
Length,  gi-owth  in,  28 
Lichen  scrofulosorum,  177,  429 
chief  characteristics,  430 
treatment,  430 
urticatus,  428 
Little's  disease,  220 
Liver,  anatomy,  23 
diseases  of,  383 
enlargement    of,    in    hereditaiy 

syphilis,  154 
in  hereditary  syphilis,  154 
Ix)bar  pneumonia,  333 
Lobular  pneumonia,  328 
Lungs,  miliary  tuberculosis  of,  180 
tuberculosis   of,   180.      See   also 
TuberculoHi'.^  of  lunr/s. 
Lymphadenitis,  312 
acute,  symptoms,  312 
chronic,  313 
treatment,  314 
Lymph-nodes  in   hereditary  syph- 
ilis, 154 
in  scrofula,  1 76 
Lymph-ring,  pharyngeal,  349 
Lymph-tissue  of  pharynx,  hyper- 
plasia of,  349 
diagnosis,  353 
treatment,  353 


Macroglossia  in  newborn,  105 
Malformations  of  newborn,  96 

fi-om  arrested  development,  96 
Management,  general,  of  disease  in 

cliildren,  68 
Manus  vara  in  newborn,  112 
Marantic   thrombosis   of    cerebral 

sinuses,  207 
Mastitis  neonatorum,  95 
Masturbation,  248 
Measles,  256 

and    erythema,    difTerentiation, 

260 
catarrhal  stage,  256 
complications,  259 
diagnosis,  259 
eruptive  stage,  257 
ex  anthem,  257 
incubation  period,  256 
Koplik's  spots  in,  257 
noma  facialis  et  vulva?  in,  259 
prognosis,  259 
symptoms,  256 
Measurements,  72 
chest,  29 
head,  30 
skull,  29 
Mechano-electric  therapeutics,  74 
Meckel's  diverticulum  in  newborn, 

107      . 
Me<licinal  treatment,  71 
Melena  neonatorum,  93 

spurious,  93 
Meningismus,  207 
Meningitis,  cerebrospinal,. 204 
coui'sc,  205 

epidemic,  diagnosis,  193 
treatment,  205 
purulent,  206 
diagnosis,  206 
differential  diagnosis,  193 
treatment,  207 
serous,  207 

differential  diagnosi.s,  194 
simple,  206 
tuberculous,  187 
course,  192 
developmont  of  symptoms  of 

cerebral  irritation,  190 
diagnosis,  193 
differential  diagnosis,  193 


INDEX 


445 


Mtningitis,  tuberculous,  final  stage, 
192 
Kemig's  sign  of,  190 
morbid  anatomy,  188 
prognosis,  192 
symptoms,  188 
treatment,  194 
Meningocele,  spinal,  100 
Mensuration,  00 

linear,  66 
Mesenteric  nodes,   tuberculosis  of, 

185 
Metabolism,  diseases  of,  anamnesis 

in,  50 
Mierocephalus,  105 
Miliaria,  421 
Miliary  tuberculosLs,  172 

of  lungs,  180 
Milk,  45 

administration  of,  47 

chief  danger,  47 
albumin  content,  diminishing,  46 
and  human  milk,  differences  in, 

45 
chemicophysicsil    differences   of, 

equalizing,  46 
comparison  of,  41 
fat  content,  loss  of.  46 
freeing  of  foreign  material   and 

Itiicteria,  45 
human,  constituents  of,  39 
of  first  two  months,  39 
permanent,  39 
mixture,    Heubner's   two-thirds, 

46 
overfeeding  with,  47 
pasteurization,  45 
sterilization,  45 
result  of,  46 
Milk-slime,  45 
Monorchism,  400 
Monstra  per  defectum,  96 
Moral  insanity,  250 
Morbilli,  256  ' 

Morbus  maculosus  Werlhofii,  147 
Mother's  marks,  406 
Mouth,  deposits  in,  removal  of,  67 

diseases  of,  342 
Movements,  35 

Mncous    membranes    in    scrofula, 
177 


Mumps,   299.     See   also  Parotitis, 

epidemic. 
Murmurs,  cardiac-pulmonary,  304 

heart,  accidental  inorganic,  305 
Muscle  anarchy  in  chorea  minor, 

241 
Muscles,  congenital  srastic  rigidity 

of,  220 
Muscidar  atrophy,  juvenile,  Erb's 

form  of,  251 
Musculature,  28 
Mustard  poultices,  71 
Myelitis,  compi-ession,  229 

transvei-se,  229 
treatment,  230 
Myehx-ystocele,  1 02 
Myelomeningocele,  100 
Myocarditis,  311 

diagnosis,  311 

symptoms,  311 

treatment,  311 
Myopathy,    primary     progressive, 
250 
diagnosis,  251 
morbid  anatomy,  250 
symptoms,  250 
treatment,  251 
Myotonia,  congenital,  239 
Myxedema,  fetal,  130,  136 

infantile,  140 
Myxidiotie,  140 

Narcotics,  73 
Nasal  diphtheria,  279 
Nephritis,  acute   parenchynmtouB, 
388 
coursCj  389 
diagnosis,  390 
morbiil  anatomy,  388 
prognosis,  390 
symj'toms,  389 
treatment,  390 
ascending,  394 
chronic,  390 
prognosis,  391 
treatment,  391 
Nephrolithiasis,  392 
symptoms,  393 
treatment,  393 
Nervines,  73 
Nervous  asthma,  323 


446 


INDEX 


Nervous  diseases,  anamnesis  in,  50 
functional,  230 

system,  anatomy,  24 
diseases  of,  204 

involvement  of,  in  hereditary 
syphilis,  157 
Nervousness,  245 

etiology,  245 

prophylaxis,  247 

treiitment,  247 
Neurasthenia,  245 

coui-se,  247 

diagnosis,  247 

prognosis,  247 

Rosenbach's  sign  of,  246 

symptoms,  245 
Nevus,  406 

flammeus,  408 

pilosus,  406 

spilus,  406 

treatment,  408 

vascular,  406 

verrucosus,  406 
Newborn,  abnormal  attachment  of 
tongue  in,  106 
number  of  fingei-s  in,  108 

acute  hemoglobinuria  of,  94 

atresia  of  anus  in,  107 

blennorrhea  of,  88 

blood-tumor  of  head  in,  94 
treatment,  95 

cephalhematoma  of,  94 

deformities    of    extremities    in, 
108 

dermoid  s|)aces  in,  96 

diseases  of,  75 

ectopia  of  bladder  in,  107 

facial  defects  in,  103 

flat-foot  in,  112 

general  loss  of  vitality  in,  75 

hypertrophy  of  tongue  in,  105 

incomplete  closure    of    cerebro- 
spinal canal  in,  96 

inversion  of  bladder  in,  107 

macroglossia  in,  105 

malformations  of,  96 

from  arrested  development,  96 

manus  vara  in,  112 

mastitis  of,  95 

Meckel's  diverticulum  in,  107 

melena  of,  93 


Newborn,  ophthalmia  of,  88 
pes  calcaneus  in,  112 
equiuus  in,  112 
valgus  in,  112 
varus  in,  112 
polydactylism  in,  108 
prolapse  of  bladder  in,  107 
ranula  in,  106 
sepsis  of,  86 

treatment,  88 
syndactylism  in,  108 
tetanus  of,  90 
treatment,  92 
Night  terrors,  248 
Noma,  346 
facialis  et  vulvae  in  measles,  259 
of  vulva,  405 
Nose  in  scrofula,  178 

secretions  frofn,  examination,  67 
Nourishment,  39 

calories     produced    by    various 
forms  of,  42 
Nursing,   improper,    gastro-intesti- 
nal  diseases  from,  359 

Obesity,  146 
Obstetric  hand,  234 
O'Dwyer's  tubes,  286 
Omphalitis,  85 
Omphakwele,  81 
Ophthalmia  neonatorum,  88 
Ossification,  endochondral,    in   ra- 
chitis, 122,  125 
normal,  in  rachitis,  122 
periosteal,  in  rachitis,  122,  124, 
125 
Osteochondritis  in  hereditary  syph- 
ilis, 165 
morbid  anatomy,  162 
Osteogenesis,  imperfect,  130,  132 
Overfeeding  with  milk,  47 
Oxyuris  vermicularis,  380 

treatment,  381 
Ozena,  316 

Palate,  cleft,  104 
Palpation,  58 

of  spleen,  62 
Paljiatory  percussion,  63 
Papilloma  of  larynx,  322 
Paralysis,  Brown-Sequard,  229 


INDEX 


447 


Paralysis,   cerebral   infantile,  217. 
St-e  also  Cerebral  injaniile pnlsy. 
Duchenne's,  250 
peripheral,  240 
pseutlolivperti-opliic,  250 
spastic  spinal,  230 
spinal  infantile,  225.     tSee  also 
Spinal  infanlUe  paraJysis. 
Paralytic  chorea,  241 
Parasites,  intestinal,  380 
diagnosis,  380 
of  skin,  435 
Parotitis,  epidemic,  299 
diagnosis,  302 
incubation  periotl,  299 
prodromal  phenomena,  300 
prognosis,  302 
submaxillary,  302 
treatment,  302 
Pasteurization  of  milk,  45 
Pea-soup  stools  in  typhoid   fever, 

292 
Pedatrophia,  366 
Pediculosis  capillitii,  432 
Peliosis,  147 
Pelvis,  anatomy  of,  20 

in  rachitis,  119 
Pemphigus  in  heretlitary  syphilis, 
153 
neonatorum,  414 
malignant  form,  415 
sjTnptoms,  414 
treatment,  415 
Percussion,  63 
auscultatory,  66 
direct,  of  bones,  63 
finger-nail-on-finger-nail  method, 

66 
finger-on-finger  method,  64 
]>alpatorv,  63 
Peribronchitis,  caseous,  in  pulmon- 
ary tuberculosis,  181 
Pericanlitis,  307 
diagnosis,  308 
treatment,  308 
tuberculous,  184 
Periomphalitis,  85 
Periosteal  ossification   in   rachitis, 

122,  124,  125 
Peripheral  paralyses,  240 
Peritoneum,  disea.ses  of,  383 


Peritoneum,  tuberculosis  of,   185. 

See   also    Tuberculosa    of  perUo- 

neuui. 
Peritonitis,  acute,  383 

chronic,  383 
treatment,  384 
Pei-spiration,  stimulation,  71 
Pertussis,  296 

convulsive  stage,  297 

diagnosis,  298 

initial  catarrhal  stage,  297 

laryngoscopic  findings  in,  296 

pathologic  findings  in,  290 

prognosis,  298 

symptoms,  297 

treatment,  299 
Pes  calcaneus  in  newborn,  112 

equinus  in  newborn,  112 

valgus  in  newborn,  112 

varus  in  newborn,  112 
Phalangitis,  syphilitic,    in    hered- 
itary syphilis,  155 
Pharyngeal  diphtheria,  277 

lymph-ring,  349 
Pharynx,  deposits  in,  removal,  67 

diseases  of,  342 

in  scrofula,  178 

lymph-tissue  of,  hviierplasia  of, 
349 
diagnosis,  353 
treatment,  353 
Phimosis,  398 

treatment,  400 
Phlegmon  of  vulva,  405 
Physiologic  i>eculiarities,  28 
Pleurisy,  337 

and   pneumonia,   diticrentiation, 
340 

course,  339 

diagnosis,  339 

dry,  338 

hemorrhagic,  337 

purulent,  337 

result,  339 

serofibrinous,  337 

serous,  337 

symptoms,  338 

treatment,  341 

tuberculous,  183 
Pneumonia,  32.S 

and  pleurisy,  difierentiatiou,  341 


448 


INDEX 


Pneumonia,  aspiration,  329 

caseous,  in   pulmonary  tubercu- 
lasis,  182 
morbid  anatomy,  181 

chiT)nic,  335 
treatment,  33G 

croupous,  333 

differential  diagnosis,  334 
prognosis,  335 
treatment,  335 

fibrinous,  333 

foreign-body,  329 

lobar,  333 

lobular,  328 

white,  160 
Polioencephalitis,  acute,  218 
Poliomyelitis,  acute  anterior,  225 
Pollakiuria,  395 

treatment,  396 
Polydactylism  in  newborn,  108 
Porrigo  larvalis,  421 
Pott's  disease,  196 
Poultices,  mustai-d,  71 
Premature  children,  75 

feeding,  76 
Preputial  epithelial  adhesion,  398 
Prognathism,  105 
Prolapse   of  bladder   in   newborn, 
107 

of  rectum  in  atrophia  infantum, 
treatment,  373 
Prurigo,  425 

chief  characteristics,  425 

prognosis,  426 

symptoms,  425 

treatment,  426 
Pseudocroup,  318 
Pseudofurunculosis,  433 
Pseudohypertroi)hic  |)ara  lysis,  250 
PseudoleuKemia,  infantile,  151 
Pseudotetanus,  236 
Psychic  treatment,  74 
Psychoses,  249 
Purpuni,  146 

alxlominal,  147 

fulminating,  148 

hemorrhagic,  147 

Henoch's,  147 

rheumatic,  147 

simple,  146 

treatment,  148 


Purpura  variolosa,  269 
Purulent  meningitis,  206 

diagnosis,  206 

differential  diagnosis,  193 

treatment,  207 
pleurisy,  337 
Pustules,     ecthyma     pustules     in, 

177 
Pyelitis,  394 
Pyelonephritis,  394 
Pyorrhea  of  umbilicus,  85 

Rachischi.sis,  99 
Rachitic  rosarv,  119 
Rachitis,  114  ' 

acute  hemorrhagic,  137 

anamnesis  in,  50 

apposition  of  bone  in,  124 

bones  preformed  in  cartilage  in, 
122 

connective-tissue    bone   in,    124, 
125 

course,  121 

ciTiniotabes  in,  114 

diagnosis,  127 
differential,  127 

diet  in,  130 

direct  results,  120 

endochondral  ossification  in,  122, 
125 

etiology,  122 

extremities  in,  119 

fetal,  130 

in  heretlitary  syphilis,  165 

macroscopic  changes  in,  124 

medication  in,  130 

microscopic  changes  in,  125 

normal  ossifiojition  in,  122 

pathologic  anatomy,  124 

pelvis  in,  119 

periosteal  ossification  in,  122, 124. 
125 

phenomena  not  directly  due  to, 
120 

prognosis,  121 

skull  in,  114 

symptoms,  114 

thorax  in,  119 

treatment,  129 

vertebne  in,  119 
Ranula  in  newborn,  106 


INDEX 


449 


Rectum,   prolapse  of,   in  atrophia 
infantum,  trejitment,  373 

taking  tempeniture  in,  53 
Reflex  epilepsy,  242 

primaiT,  231 
Respiration,  34 
Respiratory  organs,  diseases  of,  315 

anamnesis  in,  51 
Retropharyngeal  abscess,  353 
Retropluirjnigitis  in  influenza,  294 
Rheumatic  pui"pura,  147 
Rhinitis,  acute,  315 
treatment,  316 

chronic,  316 
treatment,  318 

membranacea,  279 
Rosary,  rachitic,  119 
Rosentach's  sign  of  neurasthenia, 

246 
Rubella,  261 

symptoms,  261 

Salaam  convulsions,  239 
Scabies,  431 

treatment,  432 
Scabs,  408 

Scalp,  seborrhea  of,  408 
Scarlatina  gravissima,  265 
Scarlet  fever,  262 

and  diphtheria,  differentiation, 

265 
complications,  265 
diagnosis,  265 
hemorrhagic  type,  265 
prognosis,  265 
prophylaxis,  265 
septic  types,  265 
sequelffi,  265 
special   theraiieutic  measures, 

266 
treatment,  265 
typhoidal  form,  265 
Sclerema  adiposum,  418 
edematosum,  417 
neonatorum,  417 
prophylaxis,  418 
symptoms,  417 
treatment,  418 
Sclerosis,  diffused,  224 

disseminated,  224 
Scorbutus,  infantile,  137 

29 


Scrofula,  175 

course,  178 

diagnosis,  178 

ear  in,  178 

ecthyma  pustules  in,  177 

eczema  in,  177 

eyes  in,  178 

general   hygienic    and    dietetic 
treatment,  179 

lymph-nodes  in,  1 76 

medication  in,  179 

mucous  membranes  in,  177 

nose  in,  178 

pharynx  in,  178 

phlyctenular,  keratoconjunctivi- 
tis in,  treatment,  180 

preventing  infection   of  suscep- 
tible children,  179 

prognosis,  178 

prophylaxis,  178 

skin  in,  177 

soft-soap  cure,  179 

special  treatment,  179 

subcutaneous  infiltrations  in,  177 

symptoms,  176 

treatment,  178 

tuberctilosis  and,  175 
Seborrhea,  408 

of  scalp,  408 

treatment,  411 

universal,  411 
Secretions,  67 

from  conjunctiva,   examination, 
67 

from  nose,  examination,  67 
Sepsis  of  newborn,  86 

treatment,  88 
Septic  diphtheri%  278 
Serofibrinous  pleurisy,  337 
Serous  meningitis,  207 

differential  diagnosis,  194 

pleurisy,  337 
Serum    treatment   of    diphtheria, 

281 
Sexual  organs,  diseases  of,  305 
Sinuses,    cerebral,      inflammatory 
thrombosis  of,  207 
marantic  thrombosis  of,  207 
thronilx)sis  of,  207 
Skeleton,  18 
Skin,  condition  of,  33 


450 


INDEX 


Skin,  diffuse  syphilitic  infiltration 
of,  in  hereditary  syphilis,  154 
diseases  of,  406 

general  discussion,  406 
treatment,  406 
in  hereditary  syphilis,  153 
in  scrofula,  177 
parasites  of,  435 
Skull,  anatomy,  18 
in-rachitis,  114 
measurements,  29 
Sleep,  34 

Small-pox,  267.     See  also  VnrioUi. 
Snuffles,  315 

in  hereditary  syphilis,  153 
Soft-soap  cure  of  scrofula,  179 
Spasm  of  glottis,  236 
Spasms,  230 
Sjjasmus  nutans,  539 
Spina  bifida,  99,  102 

ventosa,  196 
Spinal  cord,  diseases  of,  225 
infantile  paralysis,  225 
diagnosis,  228 
initial  stage,  225 
morbid  anatomy,  225 
prognosis,  228 
spastic,  230 

stage  of  abatement  of  paraly- 
sis, 226 
of  completed  paralysis  and 

sequeW,  226 
of  fully  developed  paraly- 
sis, 226 
symptoms,  225 
treatment,  228 
meningocele,  100 
Spleen,  enlargement  of,  -in  hered- 
itary syphilis,  153 
palpation  of,  62 
Splenic  anemia,  151 
Spondylitis,  196 
Sporadic  cretinism,  140 
Spots,  Koplik's,  257 
Sprays,  cold,  71 
Sputum,  examination,  67 
Status  lymphaticus,  323 
Stenosis,   congenital,   of    gastro-in- 

testinal  tract,  375 
Sterilization  of  milk,  45 
results,  46 


Stimulants,  73 
Stomach,  anatomy  of,  24 

atony  of,  374 
Stomatitis,  342 
aphthous,  343 
catarrhal,  342 
ulcerative,  344 
diagnosis,  345 
symptoms,  344 
treatment,  345 
Stridor  thymicus,  323 
Strophulus,  428 
Struma  of  thymus  gland,  138 
Stupes,  hot,  71 
Sl  Vitus'  dance,  240 
Submaxillary  mumps,  302 
Suppuration  fever  of  variola,  268 
Swollen  kidney,  391 
Syndactylism  in  newborn,  108 
Syphilid,    bullous,    in    hereditary 
syphilis,  153 
macular  and  papular  squamous, 
in  hereditary  syphilis,  153 
Syphilis,  congenital,  152 
hereditary,  152 
abnormal  epithelial  prolifera- 
tion in,  161 
anamnesis  in,  50 
bones  in,  154 
bullous  syphilid  in,  153 
CoUfcs'  law  of,  152 
connective-tissue  proliferation 

in,  161 
difi'iise  cellular  infiltration  in, 
161 
syphilitic  infiltration  of  skin 
in,  154 
enlargement    of    spleen    and 

liver  in,  153 
involvement  of  nervous  system 

in,  157 
kidneys  in,  154 
liver  in,  154 
lymph-nodes  in,  154 
macular  and  papular  sfpiamous 

syphilid  in,  153 
mercury  and  iodin  in,  167 
morbid  anatomy,  158 
nourishment  in,  167 
osteochondritis  in,  165 
morbid  anatomy,  162 


INDEX 


451 


Syphilis,  hereditary,  pemphigus  in, 
153 

prognosis,  167 

prophylaxis,  167 

rachitis  in,  165 

recurrence  of,  158 

skin  in,  153 

snuffles  in,  153 

symptoms,  153 

syphilitic  phalangitis  in,  155 

transmission  of,  152 

treatment,  167 

white  pneumonia  in,  161 
tarda,  156 
Syphilitic  phalangitis  in  hereditary 
syphilis,  155 

Tache  c^r^brale,  190 
Temperatui-e,  34 

taking  of,  in  rectum,  53 
Tenia  mediocanellata,  381 

solium,  381 
treatment,  381 
Terrors,  night,  248 
Testes,  undescended,  400 

treatment,  402 
Tetanus  neonatorum,  90 

treatment,  92 
Tetany,  233 

Chvostek's  sign  of,  235 

couree,  235 

diagnosis,  235 

Erb's  sign,  235 

facial    nerve     phenomenon     of, 
235 

intermittent  form,  234 

laryngospasm  of,  235 

latent,  234 

prognosis,  235 

treatment,  235 

Trousseau's  sign,  235 
Thomsen's  disease,  239 
Thorax,  anatomy,  20 

in  rachitis,  119 
Thrombosis  of  cerebral  sMnuses,  207 
inflammatory,  207 
marantic,  207 
Thrush,  345 

diagnosis,  345 

symptoms  and  course,  345 

treatment,  346 


Thymus  gland,  anatomy,  23 
diseases  of,  138 
hyperplasia  of,  324 
struma  of,  138 
Tongue,  abnormal  attachment  of, 
in  newborn,  106 
hypertrophy  of,  in  newborn,  105 
Toolh-rash,  428 
Tracheitis,  acute,  324 
morbid  anatomy,  324 
symptoms,  324 
treatment,  325 
Tracheotomy   in   diphtheria,  286, 

290 
Transverse  myelitis,  229 

treatment,  230 
Trichocephalus  dispar,  381 
Trousseau's  sign  of  tetany,  236 
Tuberculosis,  168 
abdominal,  184 
acquired,  169 
and  scrofula,  175 
congenital,  168 
frequency  of,  168 
general,  acute,  172 
chronic,  172 
diagnosis,  173 

hygienic    and    dietetic    treat- 
ment, 179 
subacute,  172 
symptoms,  172 
latent,  170  _ 
medication  in,  179 
miliary,  172 

of  lungs,  180 
of  bones  and  joints,  194 
of  bronchial  no«les,  173 
morbid  anatomy,  173 
symptoms,  173 
of  elbow,  203 
of  intestines,  184 
course,  185 
morbid  anatomy,  184 
prognosis,  184 
symptoms,  184 
treatment,  185 
of  joints  of  feet,  203 
of  knee-joint,  201 
treatment,  202 
of  lungs,  180 
acute  disseminated,  180 


462 


INDEX 


Tuberculosis  of  lungs,  caseous  peri- 
bronchitis in,  181 
pneumonia  in,  182 
morbid  anatomy,  181 

course,  182 

diagnosis,  183 

morbid  anatomy,  180 

prognosis,  182 

secondary  tuberculosis  in,  181 

symptoms,  181 

treatment,  183 
of  mesenteric  nodes,  185 
of  peritoneum,  185 

coui-se,  187 

diagnosis,  187 

morbid  anatomy,  185 

origin,  185 

prognosis,  187 

symptoms,  186 

treatment,  187 
paths  of  dissemination,  170 
peculiarities  of,  170 
phlyctenular   keratoconjunctivi- 
tis in,  treatment,  180 
predisposition  to,  170 
preventing   infection   of  suscep- 
tible children,  179 
prophylaxis,  178 
secondary,  in  pulmonary   tuber- 
culosis, 181 
special  treatment,  179 
transmission  of,  168 
treatment  of,  178 
Tuberculous  meningitis,  187.     See 

also  Meningitis,  tuberculous. 
pericarditis,  184 
pleurisy,  183 
Tumor  albus,  195 

pedis,  203 
Tumors  of  brain,  224 
Typhoid  fever,  292 

diagnosis,  203 

morbid  anatomy,  292 

pea-soup  stools  in,  292 

prognosis,  294 

symptom-complex,  292 

treatment,  294 
Typhus  inversus,  335 

Ulcerative  stomatitis,  344 
diagnosis,  345 


Ulcerative    stomatitis,    symptoms, 
344 
treatment,  345 
Umbilical  arteries,  86 
fungus,  84 
growths,  84 
hemorrhage,  84 
hernia,  acquired,  81 
treatment,  82 
congenital,  81 
funicular,  81 
Umbilicus,  diseases  of,  81 
gangrene  of,  85 
infection  of,  "85 
treatment,  86 
normal,  treatment,   81 
pyorrhea  of,  85 
Undescended  testes,  400 

treatment,  402 
Uric-acid  infarcts  in  newborn,  391 
Urinary  concretions,  391 
Urine,  examination,  67 

excretion,  35 
Urticaria,  428 
symptoms,  429 
treatment,  429 

Vaccination  against  variola,  271 
Vapor  apparatus,  325 
Varicella,  273 

confluens,  274 

bullosa  vel  ha-morrhagica,  274 

differential  diagnosis,  274 

duration,  274 

eniption,  273 

period  of  incubation,  273 

treatment,  274 
Variola,  267 

black,  269 

confluent,  269 

desiccation  fever  of,  268 

diagnosis,  269 

hsemorrhagioa  pustulosa,  269 

incubation  period,  267 

pi-ognosis,  269 

prophylaxis,  269 

stage  of  desiccation,  268 
of  eruption,  267 
of  suppuration,  267 

suppuration  fever,  268 

symptom-complex,  268 


INDEX 


453 


Variola,  treatment,  269 

vaccination  against,  271 
Vascular  nevi,  406 
Vertebiie,  anatomy,  20 
in  rachitis,  119 
tuberculous  caries  of,  196 
results,  198 
symptoms,  197 
treatment,  198 
Vertigo,  epileptic,  243 
Vesical  calculi,  393 
diagnosis,  394 
prognosis,  394 
symptoms,  393 
treatment,  394 
Vision,  35 
Vitality,  general   loss  of,   in  new- 

Iwrn,  75 
Vomiting,  habitual,  354 


Vulva,  cellular  atresia  of,  403 

diphtheria  of,  279 

gangrene  of,  405 

noma  of,  405 

phlegmon  of,  405 
Vulvovaginitis,  404 

gonorrheal,  treatment,  404 

symptoms,  404 

Warm  baths,  70 
Weaning,  indications  for,  43 
Weighing  child,  66 
Weight,  increase  in,  30 
White  kidney,  large,  391 

pneumonia,  160 

swelling  of  knee,  201 
Whooping-cough,  296.     See  also 

Pertussis. 
Winckel's  disease,  94 


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Preiswerk  and  Warren's 
Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Prof.  Gustav 
Preiswerk,  of  Basil.  Edited,  with  additions,  by  George  W. 
Warren,  M.  D.,  Professor  of  Operative  Dentistry  at  the  Penn- 
sylvania College  of  Dental  Surgery.  With  44  lithographic  plates 
in  colors,  152  text-cuts,  343  pages  of  text.     Cloth,  1^3.50  net. 

JUST   READY 

Preiswerk's  atlas  will  be  found  invaluable  to  the  practicing  dentist,  for  the 
numerous  excellent  lithographs  make  very  easy  of  comprehension  those  pro- 
cedures that  would  be  but  imperfectly  understood  from  description  alone. 
The  text,  nevertheless,  is  unusually  complete,  and  the  translation  into  English 
has  been  done  with  great  fidelity  and  smoothness.  The  editor,  Dr.  George 
W.  Warren,  has  added  much  new  matter. 

Hecker»  Trumpp,  and  Abt 
on  Children 

Atlas  and  Epitome  of  Diseases  of  Children.  By  Drs.'R. 
Hecker  and  J.  Trumpp,  of  Munich.  Edited,  with  additions,  by 
Isaac  Abt,  M.  D.,  Assistant  Professor  of  Diseases  of  Children, 
Rush  Medical  College.  With  48  lithographic  plates  in  colors, 
144  text-cuts,  and  485  pages  of  text. 

READY  SOON 

It  is  a  recognized  fact  that  the  Germans  lead  the  world  in  the  treatment  of 
children's  diseases,  and  this  magnificent  atlas  fully  maintains  this)  reputation 
The  lithographic  plates  are  wonderfully  accurate,  and  the  accompanying  text 
is  particularly  full  on  treatment.  Dr.  Isaac  Abt,  the  editor,  has  greatly  im- 
proved the  work  by  the  addition  of  all  the  latest  methods  of  treatment  and 
diagnosis. 

Each  volume  contains  from  50  to  100  colored  plates 


SAUNDERS'    MEDICAL   HAND-ATLASES 

Zuckerkandl  and  DaCosta's 
Operative  Surgery 

Second  Edition,  Revised  and  Greatly  Enlarged 


Atlas  and  Epitome  of  Operative  Surgery.    By  Dr.  O. 

Zuckerkandl,  of  Vienna.  Edited,  with  additions,  by  J.  Chal- 
mers DaCosta,  M,  D.,  Professor  of  the  Principles  of  Surgery 
and  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia. 
With  40  colored  plates,  278  text-cuts,  and  410  pages  of  text. 
Cloth,  I3.50  net. 

ADOPTED  BY  THE  U.  S.  ARMY 

In  this  new  edition  the  work  has  been  brought  precisely  down  to  date. 
The  revision  has  not  been  casual,  but  thorough  and  exhaustive,  the  entire 
text  having  been  subjected  to  a  careful  scrutiny,  and  many  improvements  and 
additions  made.  A  number  of  chapters  have  been  practically  rewritten,  and 
of  the  newer  operations,  all  those  of  special  value  have  been  described.  The 
number  of  illustrations  has  also  been  materially  increased.  Sixteen  valuable 
lithographic  plates  in  colors  and  sixty-one  text-figures  have  been  added,  thus 
greatly  enhancing  the  value  of  the  work.  There  is  no  doubt  that  the  volume 
in  its  new  edition  will  still  maintain  its  leading  position  as  a  substitute  for 
clinical  instruction. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Philadelphia  Medical  Journal 

"  The  names  of  Zuckerkandl  and  DaCosta,  the  fact  that  the  book  has  been  translated 
into  13  dififerent  lang;uages,  together  with  the  knowledge  that  it  is  used  in  the  United  States 
Army  and  Navy,  would  be  sufficient  recommendation  for  most  of  us." 

Munchener  Medidnische  Wochenschiift 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of 
operative  surgery." 

Each  volume  ia  edited,  widi  additions,  by  a  leading  specialist 


SAUNDERS'    MEDICAL   HAND-ATLASES 

Helferich  and  Blood£(ood's 
Fractures  and  Dislocations 


Atlas  and  Epitome  of  Traumatic  Fractures  and  Dis- 
locations. By  Professor  Dr.  H.  Helferich,  Professor  of 
Surgery  at  the  Royal  University,  Greifswald,  Prussia.  Edited, 
with  additions,  by  Joseph  C.  Bloodgood,  M,  D.,  Associate  in 
Surgery,  Johns  Hopkins  University,  Baltimore.  From  the  Fifth 
Revised  and  Enlarged  German  Edition.  With  216  colored 
illustrations  on  64  lithographic  plates,  190  lext-cuts,  and  353 
pages  of  text.     Cloth,  $3.00  net. 

SHOWING  DEFORMITY.  X-RAY  SHADOW,  AND  TREATMENT 

This  department  of  medicine  being  one  in  which,  from  lack  of  practical 
knowledge,  much  harm  can  be .  done,  and  in  which  in  recent  years  great 
importance  has  obtained,  a  book,  accurately  portraying  the  anatomic  rela- 
tions of  the  fractured  parts,  together  with  the  diagnosis  and  treatment  of  the 
condition,  becomes  an  absolute  necessity.  This  present  work  fully  meets 
all  requirements.  As  complete  a  view  as  possible  of  each  case  has  been 
presented,  thus  equipping  the  physician  for  the  manifold  appearances  that 
he  will  meet  with  in  practice.  The  illustrations  show  the  visible  external 
deformity,  the  X-ray  shadow,  the  anatomic  preparation,  and  the  method  of 
treatment. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  News,  New  York 

"  This  compact  and  exceedingly  attractive  little  volume  will  be  most  welcome  to  all 
who  are  interested  in  the  practical  application  of  anatomy.  The  author  and  editor  have 
made  a  most  successful  effort  to  arrange  the  illustrations  that  the  interpretation  of  what 
they  are- intended  to  present  is  exceedingly  easy." 

Brooklyn  Medical  Journal 

"  There  are  few  books  published  that  better  answer  the  requirements  for  illustration 
than  this  work  of  Professor  Helferich.  .  .  .  Such  a  collection  of  illustrations  must  be  the 
result  of  much  labor  and  thought." 

They  are  Satisfactory  Substitutes  for  Clinical  Observation 


SAUNDERS'   MEDICAL   HAND-ATLASES 

Sultan  and  Coley's 
Abdominal  Hernias 


Atlas  and  Epitome  of  Abdominal  Hernias.  By  Privat- 
DOCENT  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with  addi- 
tions, by  William  B.  Coley,  M.  D.,  Clinical  Lecturer  on  Sur- 
gery, Columbia  University  (College  of  Physicians  and  Surgeons), 
New  York.  With  119  illustrations,  36  of  them  in  colors,  and 
277  pages  of  text.     Cloth,  I3.00  net. 

DEALING  WITH  THE  SURGICAL  ASPECT 

This  new  atlas  covers  one  of  the  most  important  subjects  in  the  entire 
domain  of  medical  teaching,  since  these  hernias  are  not  only  exceedingly 
common,  but  the  frequent  occurrence  of  strangulation  demands  extraordi- 
narily quick  and  enei^etic  surgical  intervention.  During  the  last  decade  the 
operative  side  of  this  subject  has  been  steadily  growing  in  importance,  until 
now  it  is  absolutely  essential  to  have  a  book  treating  of  its  sui^cal  aspect. 
This  present  atlas  does  this  to  an  admirable  degree.  The  illustrations  are 
not  only  very  numerous,  but  they  excel,  in  the  accuracy  of  the  portrayal  of 
the  conditions  represented,  those  of  any  other  work  upon  abdominal  hernias 
with  which  we  are  familiar.  The  work  will  be  found  a  worthy  exponent 
of  our  present  knowledge  of  the  subject  of  which  it  treats. 


PERSONAL  AND  PRESS  OPINIONS 


I 


Robert  H.  M.  Dawbarn.  M.  D.. 

Pro/tsxor  of  Surgery  and  Surgical  Anatomy,  New  York  Polyclinic. 

"  I  have  spent  several  interested  hours  over  it  to-day,  and  shall  willingly  recommeiMl 
it  to  my  classes  at  the  Polyclinic  College  and  elsewhere." 

Boaton  Medical  and  Surreal  Journal 

"  For  the  general  practitioner  and  the  surgeon  it  will  be  a  very  useful  book  for  reference. 
The  book's  value  is  increased  by  the  editorial  notes  of  Dr.  Coley." 

They  have  already  appeared  in  thirteen  different  languages 


SAUNDERS'    MEDICAL   HAND  ATLASES  ^ 

Bruhl,  Politzer,  and 
MacCuen  Smith's  Otology 


Atlas  and  Epitome  of  Otology.  By  Gustav  Bruhl,  M.  D., 
of  Berlin,  with  the  collaboration  of  Professor  Dr.  A.  Politzer, 
of  Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith, 
M.  D.,  Professor  of  Otology  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  With  244  colored  figures  on  39  lithographic 
plates,  99  text-illustrations,  and  292  pages  of  text.  Cloth,  I3.00 
net. 

This  excellent  volume  is  the  first  attempt  to  supply  in  English  an  illus- 
trated clinical  handbook  to  act  as  a  worthy  substitute  for  personal  instruction 
in  a  specialized  clinic.  This  work  is  both  didactic  and  clinical  in  its  teach- 
ing, the  latter  aspect  being  especially  adapted  to  the  student's  wants. 

Clarence  J.  Blzdce,  M.  D., 

Professor  of  Otology,  Harvard  University  Medical  School ,  Boston. 
"  The  most  complete  work  of  its  kind  as  yet  published,  and  one  commending  itself  to 
both  the  student  and  teacher  in  the  character  and  scope  of  its  illustrations." 

Grtinwald  and   Newcomb's 
Mouth,   Pharynx,  Nose 


Atlas  and  Epitome  of  Diseases  of  the  Moutli,  Pliarynx, 
and  Nose.  By  Dr.  L.  Grunwald,  of  Munich.  Edited,  with 
additions,  by  James  E.  Newcomb,  M.  D.,  Instructor  in  Laryng- 
ology, Cornell  University  Medical  School.  With  200  illustra- 
tions on  42  colored  lithographic  plates,  41  text-cuts,  and  219 
pages  of  text.  Cloth,  1^3.00  net. 
Journal  of  Ophthadmology,  Otolo^,  and   Laryngolo^ 

"A  collection  of  the  most  naturally  colored  lithographic  plates  that  has  been  pub- 
lished in  any  book  in  the  English  language.  .  .  .  Very  valuable  alike  to  the  student,  the 
practitioner,  and  the  specialist." 


They  are  offered  at  a  price  heretofore  unapproached  in  cheapness 


8  SAUNDERS'  MEDICAL   HAND-ATLASES 

Sobotta  and  Huber's 
Human  Histology 

Atlas  and  Epitome  of  Human  Histology.   By  Pr.  Dr.  J. 

SoBOTTA,  of  Wiirzburg.  Edited,  with  additions,  by  G.  Carl 
HuBER,  M.  D. ,  Professor  of  Histology  and  Embryology,  Univer- 
sity of  Michigan,  Ann  Arbor.  With  214  colored  figures  on  80 
plates,  68  text-cuts,  and  248  pages  of  text.     Cloth,  $4.50  net. 

This  work  combines  an  abundance  of  well  chosen  and  most  accurate  illus- 
trations with  a  concise  text,  and  in  such  a  manner  as  to  make  it  both  atlas  and 
text-book.  The  colored  lithographic  plates  have  been  produced  with  the 
aid  of  over  thirty  colors,  and  particular  care  was  taken  to  avoid  distortion  and 
assure  exactness  of  magnification. 

Boston  Medical  and  Surreal  Journal 

"  In  color  and  proportion  they  are  characterized  by  gratifying  accuracy  and  litho- 
graphic beauty.  .  .  .  May  be  highly  recommended  to  those  who  are  without  access  to  his- 
tologic collections." 

Haab  and   deSchweinitz's 
Operative  Ophthalmolo£(y 

Atlas  and  Epitome  of  Operative  Ophthalmology.     By 

Dr.  O.  Haab,  of  Ziirich.  Edited,  with  additions,  by  George 
E.  DE  ScHWEiNiTZ,  M.  D.,  Professor  of  Ophthalmology  in  the 
University  of  Pennsylvania.  With  30  colored  lithographic 
plates,  154  text-cuts,  and  377  pages  of  text.     Cloth,  I3.50  net. 

RECENTLY    ISSUED 

This  new  ▼olame  forms  an  admirable  conclusion  of  the  series  of  atlases 
on  the  Eye  prepared  by  Professor  Haab.  Operations  are  described  with  all 
the  fidelity  and  clearness  that  thirty  years'  conscientious  practice  in  eye  work 
naturally  brings.  The  colored  illustrations  exhibit  the  same  perfection  of  art 
and  accurateness  of  detail  which  are  found  only  in  this  invaluable  series  of 
atlases. 

Unsurpassed  for  accuracy,  pictorial  beauty,  completeness,  cheapness 


SAUNDERS'    MEDICAL   HAND-ATLASES  9 

Haab  and  deSchweinitz's 
Ophthalmoscopy 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Diagnosis.  By  Dr.  O.  Haab,  of  Ziirich.  Front  the 
Third  Revised  and  Enlarged  German  Edition.  Edited,  with 
additions,  by  G.  E.  deSchweinitz,  M.  D.,  Professor  of  Oph- 
thalmology, University  of  Pennsylvania.  With  152  colored 
lithographic  illustrations;  85  pages  of  text.     Cloth,  $3.00  net. 

Not  only  is  the  student  made  acquainted  with  carefully  prepared  oph- 
thalmoscopic drawings  done  into  well-executed  lithographs  of  the  most 
important  fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic 
lesions  are  added.     It  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet.  London 

"  We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library 
of  every  hospital  into  which  ophthalmic  cases  are  received." 

Haab  and  deSchweinitz's 
External  Diseases  of  Yjy^ 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Ziirich.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  98  colored  illustrations  on  48  lithographic 
plates  and  232  pages  of  text.     Cloth,  ^3.00  net. 

SECOND  REVISED  EDITION— RECENTLY  ISSUED 

In  this  thorough  revision  the  text  has  been  brought  up  to  date  by  the  addi- 
tion of  new  matter,  including  references  to  some  of  the  modern  therapeutic 
agents.     There  have  also  been  added  eight  chromolithographic  plates. 

The  Medic&l  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity."     ( Review  of  previous  ed.) 

They  are  convenient  in  size  tuid  uniformly  bound 


lo  SAUNDERS'  MEDICAL    HAND-ATLASES 

Durck  and  Hektoen's 
General  Patholo£(ic  Histolo^ 

Atlas  and  Epitome  of   General  Pathologic  Histology. 

By  Pr.  Dr.  H.  Durck,  of  Munich.  Edited,  with  additions,  by 
LuDViG  Hektoen,  M.  D.,  Professor  of  Pathology,  Rush  Medical 
College,  Chicago.  172  colored  figures  on  77  lithographic  plates, 
36  text-cuts,  many  in  colors,  and  453  pages  of  text.    1^5.00  net. 

JUST  ISSUED 

This  new  atlas  gives  the  accepted  views  in  regard  to  the  significance  of 
pathologic  processes.  All  the  illustrations  have  been  made  from  original 
specimens  without  combining  different  microscopic  fields.  Extraordinary  care 
has  been  taken  to  reproduce  them  as  near  perfection  as  possible,  in  many 
cases  twenty-six  colors  being  required. 

Diirck  and  Hektoen's 
Special  Pathologic  Histolo£(y 

Atlas  and   Epitome  of  Special  Pathologic   Histology. 

By  Dr.  H.  Durck,  of  Munich.  Edited,  with  additions,  by 
LuDviG  Hektoen,  M.  D.,  Professor  of  Pathology,  Rush  Medical 
College,  Chicago.  In  Two  Parts.  Part  I. — Circulatory,  Respira- 
tory, and  Gastro-intestinal  Tracts.  Part  II. — Liver,  Urinary  and 
Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and  Bones.  243 
colored  figures  on  122  plates,  and  350  pages  of  text.  Per  part: 
Cloth,  |3,oo  net. 

WmiMn  H.  Welch.  M.  D.. 

Profttsor  0/ Pathology,  Johns  Hopkins  University,  Baltimort. 

"  I  consider  Durck's  'Atlas  of  Special  Patholopc  Histology,'  edited  by  Hektoen,  a  Tery 
useful  book  for  students  and  others.     The  plates  are  admirable." 

They  represent  the  best  artistic  and  professional  talent 


SAUNDERS'    MEDICAL   HAND-ATLASES  ii 

Lehmann,  Neumann,  and 
Weaver's  Bacteriology 


Atlas  and  Epitome  of  Bacteriology :  including  a  Text- 
Book  OF  Special  Bacteriologic  Diagnosis.  By  Prof,  Dr. 
K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  From 
the  Second  Revised  and  Enlarged  German  Edition.  Edited, 
with  additions,  by  G.  H.  Weaver,  M.  D.,  Assistant  Professor 
of  Pathology  and  Bacteriology,  Rush  Medical  College,  Chicago. 
In  two  parts.  Part  I. — 632  colored  figures  on  69  lithographic 
plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  1 2. 50  net. 

INCLUDING  SPECIAL  BACTERIOLOGIC  DIAGNOSIS 

This  work  furnishes  a  survey  of  the  properties  of  bacteria,  together  with 
the  causes  of  disease,  disposition,  and  immunity,  reference  being  constantly 
made  to  an  appendix  of  bacteriologic  technic.  The  special  part  gives  a 
complete  description  of  the  important  varieties,  the  less  important  ones  being 
mentioned  when  worthy  of  notice.  The  lithographic  plates,  as  in  all  this 
series,  are  accurate  representations  of  the  conditions  as  actually  seen,  and 
this  collection,  if  anything,  is  more  handsome  than  any  of  its  predecessors. 
As  an  aid  in  original  investigation  the  work  is  invaluable. 


OPINIONS  or  THE  MEDICAL  PRESS 


American  Journal  of  the  Medical  Sciences 

"  Practically  all  the  important  organisms  are  represented,  and  in  such  a  variety  of 
Torms  and  cultures  that  any  other  atlas  would  rarely  be  needed  in  the  ordinary  hospital 
laboratory." 

The  Lancet,  London 

"  We  have  found  the  work  a  more  trustworthy  guide  for  the  recognition  of  unfamiliar 
species  than  any  with  which  we  are  acquainted." 

There  have  been  82,000  copies  imported  since  publication 


12  SAUNDERS'    MEDICAL   HAND-ATLASES 

Schaffer  arid  Edgar's 
Labor  anS  Operative  Obstetrics 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Fifth  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by 
J.  Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics  and  Clinical 
Midwifery,  Cornell  University  Medical  School.  14  lithographic 
plates  in  colors;  139  other  cuts  ;   in  pages  of  text.     ^2.00  net. 

The  book  presents  the  act  of  parturition  and  the  various  obstetric  opera- 
tions in  a  series  of  easily  understood  illustrations.  These  are  accompanied 
by  a  text  that  treats  the  subject  from  a  practical  standpoint. 

Dublin  Journal  of  Medical  Science,  Dublin 

"  One  fault  Professor  Schaffer's  Atlases  possess.  Their  name,  and  the  extent  and 
number  of  the  illustrations,  are  apt  to  lead  one  to  suppose  that  they  are  merely  '  atlases/ 
whereas  the  truth  really  is  they  are  also  concise  and  modem  epitomes  of  obstetrics." 

Schaffer  &  Ed£(ar's  Obstetric 
Diagfnosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treat- 
ment. By  Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Sec- 
ond Revised  German  Edition.  Edited,  with  additions,  by  J. 
Clifton  Edgar,  M,  D.,  Professor  of  Obstetrics  and  Clinical 
Midwifery,  Cornell  University  Medical  School.  122  colored  fig- 
ures on  56  plates;  38  other  cuts;  315  pages  of  text.     ^3.00  net. 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the 
wealth  of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of 
great  value.     This  text  deals  with  the  practical,  clinical  side  of  the  subject. 

New  York  Medical  Journal 

"  The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the 
text  can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but  as  expounding  the 
scientific  midwifery  of  to-day. 

These  are  the  famous  "  Lehmann  medidnische  Handatlanten  " 


SAUNDERS'    MEDICAL   HAND-ATLASES  13 

Mracek   and  Stelwag^on's 
Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.    By  Prof. 

Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
Henry  W.  Stel wagon,  M.  D.,  Professor  of  Dermatology  in 
the  Jefferson  Medical  College,  Philadelphia.  With  77  colored 
plates,  50  text-cuts,  and  288  pages  of  text.     Cloth,  ^4.00  net. 

JUST  ISSUED— NEW  (2d)  EDITION 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  con- 
tains, together  with  colored  plates  of  unusual  beauty,  numerous  illustrations 
in  black,  and  a  text  comprehending  the  entire  field  of  dermatology.  The 
illustrations  are  all  original  and  prepared  from  actual  cases  in  Mracek' s  clinic. 

American  Journal  of  the  Medical  Sciences 

"  The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are : 
First,  its  handiness;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color, 
and  the  diagnostic  points  which  they  bring  out.     We  most  heartily  recommend  it." 

Mracek  and  Bang^'s 
Syphilis  arid  Venereal  Diseases 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Dis- 
eases. By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with 
additions,  by  L.  Bolton  Bangs,  M.  D.,  late  Prof,  of  Genito- 
urinary Surgery,  University  and  Bellevue  Hospital  Medical 
College,  New  York.  With  71  colored  plates  and  122  pages 
of  text.     Cloth,  ^^3.50  net; 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  whom 
the  original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty 
anything  of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Ger- 
many, but  throughout  the  literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of  "  The  American  Text-Book  of  Obstetrics." 

"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  raluable,  and 

r-aphic  character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and  the  Venereal   Diseases.' 
know  of  nothing  in  this  country  that  can  compare  with  it." 

The  Udio^raphs,  all  made  in  Germany,  are  unrivalled  ' 


14  SAUNDERS'  MEDICAL    HAND-ATLASES 

Schaffer  and  Webster's 
Operative  Gynecology 

Atlas  and  Epitome  of  Operative  Gynecology.    By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J. 
Clarence  Webster,  M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of 
Obstetrics  and  Gynecology  in  the  Rush  Medical  College,  in  affili- 
ation with  the  University  of  Chicago.  With  42  lithographic 
plates  in  colors,  many  text-cuts,  a  number  in  colors,  and  138 
pages  of  text.     Cloth,  ;^3.oo  net. 

RECENTLY  ISSUED 

The  excellence  of  the  lithographic  plates  and  the  many  other  illustrations 
in  this  atlas  render  it  of  the  greatest  value  in  obtaining  a  sound  and  practical 
knowledge  of  operative  gynecology.  Indeed,  the  artist,  the  author,  and  the 
lithographer  have  expended  much  patient  endeavor  in  the  preparation  of  the 
water-colors  and  drawings.  They  are  based  on  hundreds  of  photographs 
taken  from  nature,  and  tibey  reproduce  faithfully  and  instructively  the  various 
situations.     The  text  closely  follows  the  illustrations,  and  is  fully  as  accurae. 

Shaffer  and  Norris* 
Gynecology 

Atlas  and  Epitome  of  Gynecology.    By  Dr.  O.  Shaffer, 

of  Heidelberg.     From  the  Second  Revised  and  Enlarged  German 

Edition.    Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 

M.  D.,  Gynecologist  to  Methodist-Episcopal   and   Philadelphia 

Hospitals.     With  207  colored  figures  on  90  plates,  65  text-cuts, 

and  308  pages  of  text.     Cloth,  1^3.50  net. 

The  value  of  this  atlas  will  be  found  not  only  in  the  concise  explanatory 
text,  but  especially  in  the  illustrations.  The  large  number  of  colored  plates, 
reproducing  the  appearance  of  fresh  specimens,  will  give  the  student  a  knowl- 
edge of  the  changes  induced  by  disease  that  cannot  be  obtained  from  mere 
description. 

Bulletin  of  Johns  Hopkins  Hospital,  Baltimore 

"  The  book  conuiins  much  valuable  material.  Rarely  have  we  seen  such  a  valuable 
collection  of  gynecological  plates." 

Theie  books  are  next  b«st  to  actual  clinical  work 


SAUNDERS'    MEDICAL   HAND-ATLASES  15 

Jakob  and  £shner's 
Internal  Medicine  &  Diagnosis 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with 
additions,  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clin- 
ical Medicine  in  the  Philadelphia  Polyclinic.  With  182  colored 
figures  on  68  plates,  64  illustrations  in  black  and  white,  and 
259  pages  of  text.     Cloth,  ^3.00  net. 

In  addition  to  an  admirable  atlas  of  clinical  microscopy,  this  volume 
describes  the  physical  signs  of  all  internal  diseases  in  an  instructive  manner 
by  means  of  fifty  colored  schematic  diagrams.  As  a  means  of  instructioD 
its  value  is  very  great ;  as  a  reference  handbook  it  is  admirable. 

British  Medical  Journal 

"  Dr.  Jakob's  work  deserves  nothing  but  praise.  The  information  is  acctirate  and  up 
to  present-day  requirements." 

Grunwald  and  Grayson's 
Diseases  of  the  Larynx 


Atlas  and  Epitome  of  Diseases  of  the  Larynx.     By  Dr. 

L.  Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles 
P.  Grayson,  M.  D.,  Clinical  Professor  of  Laryngology  and 
Rhinology,  University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-illustrations,  and  103  pages  of  text. 
Cloth,  $2.50  net. 

This  atlas  exemplifies  a  happy  blending  of  the  didactic  and  clinical,  such 
as  is  not  to  be  found  in  any  other  volume  upon  this  subject.  The  author 
has  given  special  attention  to  the  clinical  portion  of  the  work,  the  sections 
on  diagnosis  and  treatment  being  particularly  full. 

The  Medical  Record,  New  York 

"  This  is  a  good  work  of  reference,  being  both  practical  and  concise.  ...  It  b  a  valu- 
able addition  to  existing  laryngeal  text-books." 

For  "  Special  Offer  "  re^ardinj  these  atlases  see  page  I 


i6  SAUNDERS'  MEDICAL   HAND-ATLASES 

Hofmann  and  Peterson's 
Legfal  Medicine 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of 
Vienna.  Edited  by  Frederick  Peterson,  M.  D.,  Clinical  Pro- 
fessor of  Psychiatry,  College  of  Physicians  and  Surgeons,  N.  Y. 
1 20  colored  figures  on  56  plates,  193  text-cuts.  $3.50  net. 
The  Practitioner.  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection 
with  this  department  of  medicine,  and  they  cannot  fail  to  be  usenil  alike  to  the  medical 
jurist  and  to  the  student  of  forensic  medicine." 

Jakob  and  Fisher's 
Nervous  System  and  its  Diseases 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases.  By  Prof.  Dr.  Chr.  Jakob,  of  Erlangen.  From  the 
Second  Revised  German  Edition.  Edited,  with  additions,  by 
Edward  D.  Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous 
System,  University  and  Bellevue  Hospital  Medical  College,  N.  Y. 
83  plates  and  copious  text.  Cloth,  I3.50  net. 
Philadelphia  Medical  Journal 

"We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  scientific  fidelity  of  this  hand-atlas." 

Golebiewski  and  Bailey's 
Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions, 
by  Pearce  Bailey,  M.  D.,  Consulting  Neurologist  to  St.  Luke's 
Hospital  and  Orthopedic  Hospital,  N.  Y.  71  colored  illustrations 
on  40  plates,  143  text-cuts,  549  pages  of  text.  Cloth,  $4.00  net. 
Medical  Examiner  and  Practitioner 

"  It  is  a  useful  addition  to  life-insurance  libraries,  for  lawyers,  physicians,  and  hx  every 
one  who  is  brought  in  contact  with  the  treatment  or  consideration  of  accidents  or  diseases 
growing  out  of  them,  or  legal  complications  flowing  from  them. 

The  "  Atlas  of  Operative  Surgery  "  has  been  adopted  by  U.  S.  Army 


SAUNDERS'  MEDICAL  HAND-ATLASES 


Atlas    and    Epitome    of   External    Diseases   of   the 

Eye.  By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  DE 
SCHWEINITZ,  M.D.,  Professor  of  Ophthalmology  in  the  University  of  Penn- 
sylvania. Second  Revised  Edition.  With  98  colored  illustrations  on  48 
plates  and  232  pages  of  text.  Cloth,  ^^3.00  net. 

"  The  work  is  well  done,  and  is  valuable  to  physicians  in  general,  as  well  as  to  ophthal- 
mologists.  I  shall  take  pleasure  in  recommending  it."— John  E.  Wbbks,  M.D..  Clinical 
Professor  of  Ophthalntolo^ ,  University  of  Bellevue  Hospital  Medical  School,  N.  Y 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 

Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  addi- 
tions, by  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine  in 
the  Philadelphia  Polyclinic.  With  179  colored  figures  on  68  plates  and 
259  pages  of  text.  Cloth,  ;j!3.oo  net. 

"  Dr.  Jakob's  work  deserves  nothing  but  praise.  The  information  is  accurate  and  up  to 
present-day  requirements." — British  Medical  Journal. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna. 
Edited,  with  additions,  by  Frederick  Peterson,  M.  D.,  Clinical  Pro- 
fessor of  Psychiatry,  College  of  Physicians  and  Surgeons,  New  York. 
With  120  colored  figures  on  56  plates  and  193  half-tone  illustrations. 

Cloth,  $3.50  net 

"  It  is  rare  indeed  that  so  large  a  series  of  illustrations  are  found  which  demonstrate  to 
well  and  so  accurately  the  conditions  which  they  are  supposed  to  represent." — Boston 
Medical  and  Surgical  Journal 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.    By  Dr. 

L.  Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  Clinical  Professor  of  Laryngology  and  Rhinology  in  the 
University  of  Pennsylvania.  With  107  colored  figures  on  44  plates,  25 
text-illustrations,  and  I03  pages  of  text.  Cloth,  $2.50  net. 

"  Excels  everything  we  have  hitherto  seen  in  the  way  of  colored  illustrations  of  diseases 
of  the  larynx." — British  Medical  Journal. 

Atlas  and  Epitome  of  Operative  Surgery.    By  Dr.  o. 

ZucKERKANDL,  of  Vienna.  Fro7n  the  Second  Revised  and  Enlarged  Ger- 
man Edition.  Edited,  with  additions,  by  J.  Chalmers  DaCosta,  M.D., 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.  Second  Edition,  Revised  and  Greatly  En- 
larged.    With  40  colored  plates,  278  text-cuts,  and  410  pages  of  text. 

Cloth,  I3. 50  net. 
"  It  may  be  said  that  few,  if  any,  books  of  this  description  are  so  comprehensive  in  their 
scope." — Philadelphia  Medical  Jour  nal . 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Dis- 
eases. By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  ad- 
ditions, by  L.  Bolton  Bangs,  M.D.,  late  Professor  of  Genito-Urinary  Sur- 
gery, University  and  Bellevue  Hospital  Medical  College,  New  York.  With 
71  colored  plates  and  122  pages  of  text.  Cloth,  $^-^0  net. 

"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  Association. 

Atlas  and  Epitome  of  Skin  Diseases.    By  Prof.  Dr.  Franz 

Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry  W.  Stelwagon, 
M.D.,  Professor  of  Dermatology  in  the  Jefferson  Medical  College, 
Philadelphia.  With  77  colored  plates,  50  half-tone  illustrations,  and  288 
pages  of  text. 

"  The  illustrations  are  very  well  executed,  and  the  coloring  remarkably  accurate  ;  they 
will  serve  as  substitutes  for  clinical  observation." — Medical  Record,  New  York. 

Atlas  of  Bacteriology  and  Text-Book  of  Special  Bac- 
teriologic  Diagnosis.  By  Prof.  Dr.  K.  B.  Lehmann  and  Dr. 
R.  O.  Neumann,  of  Wurzburg.  From  the  Second  Revised  aud  Enlarged 
German  Edition.  Edited,  with  additions,  byG.  H.  Weaver,  M.D.,  As- 
sistant Professor  of  Pathology  and  Bacteriology,  Rush  Medical  College, 
Chicago.  Two  volumes.  Part  I. — 632  colored  figures  on  69  plates.  Part 
II. — 5'^  pages  of  text,  illustrated.  Per  volume:  Cloth,  ^2.50  net. 

"  The  illustrations  .  .  .  are  works  of  art ;  they  are  true  in  color  and  relationship  and  are 
much  superior  to  the  usual  photographic  reproductions." — Buffalo  Medical  Journal. 


University  of  California 

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405  Hllgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

from  which  it  was  borrowed. 


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Biomedical  Library 

JUN  1  2  1991 

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Atlas  and  Epitome  of  Ophthalmoscopy  and  pphOjal- 

by  G.  E.  deSchwkinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Uni 
versity  of  Pennsylvania.     With  152  colored  figures;  82  P,^j^^^°J^'^^'-net. 

"Nowl^.Uec.nbefound^ch..fi„e^^^^^^^^ 


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Atlas  and  Epitome  of  Otology 

lin,  with  the  collaboration  of  Pro"  '^ 
with  additions,  by  S.  MacCukn 
the  Jefferson  Medical  College,  PI 
lithotrraphic  plates,  99  text-cuts,  a 

Atlas  and  Epitome  of  Abdc  "^  .ornias.   By  Privatdo- 

CENT  Dr.  Georg  Sultan,  of  Goitii.gen.  Edited,  with  additions,  by  Wil- 
liam B.  COLEY,  M.D.,  Clinical  Lecturer  on  Surgery,  Columbia  Univer- 
sity, N.  Y.     119  illustrations,  36  in  colors;  277  pages  of  text. 

Cloth,  I3.00  net. 

Atlas  and  Epitome  of  Traumatic  Fractures  and  Dislo- 
cations. By  Prof.  Dr.  H.  Helferich,  of  Greifswald.  Edited,  with 
additions,  by  Joseph  C.  Bloodgood,  M.D.,  Associate  in  Sui^ery,  Johns 
Hopkins  University,  Baltimore.  With  216  colored  figures  on  64  litho- 
graphic plates,  190  text-cuts,  and  353  pages  of  text.         Cloth,  $3.00  net. 


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IRVINE,  CALIFORNIA  92664 


